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A/ 


A  TREATISE 


ON 


SURGERY 


BY 

GEORGE  RYERSON  FOWLER,  M.D. 

BROOKLYN — NEW    YORK    CITY 

EXAMINER    IN    SURGERY,    BOARD   OF    MEDICAL   EXAMINERS   OF    THE    REGENTS   OF   THE 
UNIVERSITY   OF   THE   STATE  OF   NEW   YORK  ;    EMERITUS   PROFESSOR    OF   SUR- 
GERY IN  THE    NEW  YORK  POLYCLINIC;    SURGEON  TO   THE   METHODIST 
EPISCOPAL   HOSPITAL;    SURGEON-IN-CHIEF   TO   THE    BROOKLYN 
hospital;    SURGEON    TO    THE    GERMAN    HOSPITAL 


Containing  888  Text-Illustrations 
and  Four  Colored  Plates,  all  Original 


VOLUME  I 


PHILADELPHIA   AND    LONDON 

W.    B.    SAUNDERS   COMPANY 

1906 


Copyright,   1906,  by  W.  B.  Saunders  Company 


PRESS      OF 

V.      B.      SAUNDERS      COMPANY 

PM  I  l_ADei_PHIA 


TO  MY  WIFE 

WHOSE  DEVOTION  HAS  ENABLED  ME  TO 
WRITE  THIS  BOOK 


PREFACE 


In  presenting  a  new  work  on  Surgery  the  author  has  endeavored  to  bring 
together  the  most  recent  and  improved  methods  of  surgical  practice,  and, 
with  the  aid  of  numerous  cross-references,  to  arrange  these  in  a  form  readily 
available  to  the  student  and  practitioner.  As  a  necessary  preliminary  to 
this,  the  so-called  art  of  surgery,  the  effort  has  been  made  to  set  forth  the 
fundamental  principles  underlying  what  is  known  as  the  science  of  surgery 
in  both  an  interesting  and  an  instructive  manner. 

The  study  of  inflammation  from  the  surgical  viewpoint  is  based  on  the 
tissue  changes  that  follow  the  infliction  of  wounds.  Contrary  to  the  usual 
custom  the  subject  of  Surgical  Bacteriology  is  introduced  in  connection  with 
the  etiology  of  inflammation,  in  which  it  is  an  important  factor. 

The  grouping  of  the  topics  differs  somewhat  from  the  arrangement  usually 
employed,  as  will  be  seen  by  reference  to  the  table  of  contents.  It  is 
believed  that  the  study  of  the  subject  will,  be  facilitated  by  this  method  of 
classification. 

The  section  on  Laboratory  Aids  in  Surgical  Diagnosis  and  Prognosis  it 
is  believed  wall  be  specially  valuable,  owing  to  the  increasing  interest  in  hem- 
atology, urinology,  and  kindred  subjects. 

The  practical  part  of  the  work  comprises  a  separate  consideration  of  the 
injuries  and  diseases  of  each  region.  This,  the  anatomic  method,  it  is  hoped 
will  appeal  to  the  surgical  clinician,  particularly  with  reference  to  diagnosis. 

The  section  on  Surgical  Bacteriology  is  the  work  of  Dr.  A.  T.  Bristow,  and 
the  section  on  Laboratory  Aids  in  Surgical  Diagnosis  and  Prognosis  that  of  Dr. 
F.  E.  Sondern.  I  wish  to  express  my  indebtedness  to  these  gentlemen  for  their 
valuable  contributions. 

The  aid  rendered  by  Dr.  W.  C.  Wood  in  connection  with  the  section  on 
Injuries  and  Diseases  of  the  Bones  and  Joints,  by  Dr.  Russell  S.  Fowler  in  the 
preparation  of  the  section  on  Bandaging  and  other  portions  of  the  text,  by 
Dr.  G.  E.  Buist  in  connection  with  the  section  on  Surgical  Anesthesia,  and  by 
Dr.  T.  B.  Spence  is  gratefully  acknowledged. 

My  thanks  are  due  also  to  my  clinical  assistants.  Dr.  J.  E.  Jennings,  Dr. 
C.  F.  Buckky,  and  Dr.  Carl  Fulda,  for  efficient  help  in  the  work,  and  to  my  hospi- 
tal internes  for  the  compilation  of  clinical  material  from  the  records  of  my 
hospital  services. 

The  final  preparation  of  the  manuscript  as  w^ell  as  the  supervision  of  the 
passage  of  the  sheets  through  the  press  is  the  work  of  Miss  Annie  T.  Keyser, 
Editor  and  Proof  Reader  of  Question  Papers,  New  York  State  Education 
Department,  to  whose  faithful,  painstaking,  and  efficient  cooperation  in  bring- 
ing out  the  book  I  am  greatly  indebted. 


VI  PREFACE 

The  illustrations  are  the  work  of  Mr.  F.  A.  Deck,  to  whose  skill  is  due  the 
aid  that  these  furnish  in  the  elucidation  of  the  text. 

Finally,  I  wish  to  extend  my  acknowledgments  to  the  publishers  for  their 
unremitting  endeavors  to  make  the  work  represent  the  highest  ideal  of  the 
bookmaker's  art. 

George  Ryerson  Fowler. 
Brooklyn,  New  York  City 
January,  1906. 


CONTENTS 


GENERAL  SURGERY 

Page 

Inflammation 1 

Wounds 1 

Inflammation  in  General 8 

Etiology 14 

General  Diagnosis 33 

Termination  and  Prognosis 38 

Surgical  Fever 39 

Treatment 48 

Injuries  and  Diseases  of  Separate  Tissues 66 

The  Skin  and  Subcutaneous  Connective  Tissue 66 

Blood-vessels 85 

Lymphatic  Vessels  and  Lymphatic  Glands 107 

Nerves '.  .  .  .  114 

Fasciae,  Muscles,  and  Tendons 120 

Bones 123 

Joints 146 

Gunshot  Injuries 165 

Acute  Wound  Diseases 177 

Erysipelas 177 

Erysipeloid 179 

Hospital  Gangrene 180 

Malignant  Edema;  Acute  Purulent  Edema 181 

Infectious  Emphysema 182 

Septicemia 182 

Pyemia 184 

Tetanus 187 

Hydrophobia .' 190 

The  Chronic  Surgical  Infections 194 

Syphilis 194 

Tuberculosis 205  ■ 

Actinomycosis , 209 

Tumors 214 

Classification 214 

Diagnosis 241 

Treatment 242 

vii 


Vlll  CONTENTS 

Page 

Laboratory  Aids  in  Surgical  Diagnosis  and  Prognosis 243 

Pathologic   Examinations 244 

Bacteriologic  Examinations 247 

Chemic  Examinations 248 

Examination  of  the  Blood 248 

Urine  Analysis 259 

ExaiTiination  of  Sputum 273 

Examination  of  Gastric  Contents 274 

Examination  of  Feces 276 

Examination  of  Aspirated  Fluids 277 

Surgical  Operations  in  General 280 

General  Considerations 280 

Common  Dangers 281 

Special  Dangers 283 

Post-operative  Complications 284 

Surgical    Anesthesia 288 

Local  Anesthesia 304 

Spinal  Anesthesia 306 

The  General  Principles  of  Operative  Technic 308 

The  Separation  of  Tissues 308 

Indications  for  Uniting  the  Tissues;  Mechanism  of  Uniting  the  Tissues. 321 

Operations  on  Individual  Structures 327 

Skin 327 

Blood-vessels 336 

Nerves 354 

Muscles  and  Tendons 357 

Bones 361 

Joints 370 

Amputations  and  Disarticulations 376 

Foreign  Bodies 383 

Bandaging 388 


REGIONAL   SURGERY 

Surgery  of  the  Head 429 

Scalp 429 

Cranial  Bones 434 

Brain 455 

Soft  Parts  of  the  Facial  Region 474 

Soft  Parts  of  the  Nose  and  Nasal  Cavities 495 

Frontal  Sinuses 514 

Jaws , 519 

Nerves  of  the  Facial  Region 540 


CONTENTS  IX 

Page 

Tongue 545 

Soft  and  Hard  Palate 558 

Fauces,  Pharynx,  and  Nasopharynx 566 

Ear 578 

Salivary  Glands 586 

Surgery  of  the  Neck 594 

Larynx,  Trachea,  and  Hyoid  Bone 594 

Thyroid  Gland 610 

Esophagus 617 

Lateral  Region  of  the  Neck 624 

Cervical  Vertebrae 641 

Surgery  of  the  Thorax 652 

Soft  Parts  Surrounding  the  Chest 652 

Bony  Chest  Walls 670 

Lungs 681 

Heart  and  Pericardium , 684 

Index  of  Names 687 

Index 693 


A  TREATISE  ON  SURGERY 


PART  I 
GENERAL  SURGERY 


SECTION  I 
INFLAMMATION 

Inflammation,  as  viewed  from  the  surgical  standpoint,  is  that  series  of 
changes  in  the  tissues  which  takes  place  as  the  result  of  injury  plus  infection. 
In  the  absence  of  infection  and  during  the  repair  of  an  injury,  however,  the 
processes  concerned  are  histologically  identical  with  those  concerned  in  inflam- 
mation. But  the  differences  in  degree  and  extent  are  such  as  to  stamp  the 
one  as  a  pathologic  process  and  the  other  as  a  physiologic  process.  The  study 
of  the  phenomena  will  therefore  naturally  commence  with  the  injury  itself. 

WOUNDS 

A  wound  is  the  forced  separation  of  any  portion  of  the  skin  or  mucous 
membrane  so  that  the  protective  covering  of  the  underlying  tissues  is 
destroyed  and  the  latter  exposed  to  the  influence  of  the  air  and  other 
extraneous  matters. 

Classification  and  Mechanism.— Wounds  of  the  external  surface  of 
the  body  involving  exposure  of  the  subcutaneous  connective  tissue  are 
di'vided,  according  to  the  condition  of  the  edge  of  the  wound,  into  those 
possessing  (1)  well-defined  edges;  (2)  lacerated  solutions  of  continuity  of  the 
surface;  (3)  contused  breaches  of  tissue. 

Wounds  with  well-defined  and  sharp  edges  are  subdivided  into  incised  and 
punctured  wounds.  Lacerated  wounds  occur  where  there  is  excessive 
tension  on  the  skin  by  the  application  of  a  dragging  force,  or  where  the 
tissues  are  forced  against  some  unyielding  part,  as,  for  instance,  the  skuU. 

Contused  wounds  are  caused  by  contact  of  the  body  ■v^'ith  an  object 
having  a  broad  surface,  or  by  falls  upon  hard  angular  surfaces.  Wounds 
resulting  from  the  blow  of  a  club,  or  from  the  entrance  into  the  body  of  some 
missile  (gunshot  wounds),  are  familiar  examples  of  contused  wounds. 

In  addition  to  these,  wounds  are  spoken  of  as  penetrating  when  the  foreign 
bodv  enters  a  cavitv  of  the  body  without  emerging:  as  perforating  when 
2  '  '        1 


2  INFLAMMATION 

the  foreign  body  enters  and  emerges.  If  some  specific  poison  has  been  car- 
ried into  the  wound  and  has  infected  it,  it  is  then  spoken  of  as  a  poisoned 
wound. 

Wounds  are  likewise  said  to  be  septic  or  aseptic,  according  as  they  have 
been  infected  or  not  mth  those  organisms  which  excite  putrefaction  or  other 
disorganization  of  tissue.  Destruction  of  tissue  to  a  greater  or  lesser  extent 
characterizes  all  wounds. 

Symptoms. — A  symptom  common  to  all  wounds  is  separation  and  gaping 
of  its  edges.  This  is  caused  by  the  presence  of  elastic  fibers  in  the  connective 
tissue  and  cutis,  and  emphasizes  the  elasticity''  characteristic  of  the  uninjured 
skin.  The  degree  of  gaping  depends  on  the  number  and  direction  of  the 
elastic  fibers,  as  well  as  on  the  depth  of  the  wound.  If  the  wound  separates 
the  tissues  in  a  direction  parallel  to  that  of  the  elastic  fibers,  the  gaping  will 
be  less  than  when  these  are  separated  in  a  transverse  direction.  Deep  wounds 
gape  more  than  superficial  ones. 

The  hemorrhage  which  accompanies  a  wound  depends  on  the  depth, 
length,  and  breadth  of  the  wound,  as  well  as  on  the  size  and  condition  of  the 
divided  blood-vessels.  As  a  rule,  this  symptom  is  less  marked  in  contused 
and  lacerated  wounds  than  in  those  with  clean-cut  and  sharply  defined  edges. 

The  symptom  of  pain  is  usually  an  immediate  accompaniment  of  a  wound, 
and  results  from  the  injury  and  irritation  of  the  numerous  fibers  of  sensor\' 
nerves  in  the  injured  tissues.  It  is  of  a  sharp,  burning  character  and  radiates 
along  the  nerve-tn,mk  or  in  the  area  of  its  distribution.  The  more  rapidly  and 
thoroughly  the  nerve-fibers  are  divided,  the  less,  as  a  rule,  is  the  pain.  It  may 
happen  that  no  pain  whatever  is  experienced,  owing  to  the  rapidity  with  which 
the  wound  is  inflicted,  or  to  mental  excitement  at  the  time  of  the  injury.  In 
clean  incised  wounds  the  wounded  person  may  not  be  aware  that  he  is  injured 
until  his  attention  is  attracted  by  the  presence  of  blood.  Contused  wounds 
are  the  most  painful  of  injuries.  Individual  temperament  also  may  modify 
the  amount  of  pain.  Courageous  persons  and  those  in  a  furious  rage,  on  the  one 
hand,  and  those  exercising  a  quiet  self-control,  on  the  other,  suffer  the  least,  for 
these  conditions  act  as  restraining  influences  on  the  sensory  cortical  centers. 

Healing  by  Primary  Intention,  i.e.,  without  Suppuration. — Wounds 
with  sharph-  defined  edges  and  but  slight  separation  may  heal  in  a  relatively 
short  time,  no  essential  change  being  discoverable  in  the  wound  and  its  sur- 
roundings. A  very  narrow  blood-coagulum  fills  the  interspace  and  causes 
agglutination  of  its  edges,  while  the  upper  layers  of  this  coagulum  projecting 
just  beyond  the  edges  become  dried  and  form  a  thin  line  or  scab,  hermetically 
sealing  the  wound.  In  the  earlier  stage  of  this  reparatiA'e  process  the  wound 
may  be  reopened  by  ver}'  slight  violence,  but  as  organization  takes  place  in 
the  thin  cement  of  blood-clot,  union  becomes  firmer,  until  finally  the  narrow 
surface  scab  falls  off,  leaving  a  bluish  or  purple  furrow  covered  with  new  and 
tender  epidermis — the  cicatrix.  The  period  of  time  occupied  by  the  healing 
process  varies  with  the  degree  of  separation  of  the  edges  of  the  original  wound. 
Small  incised  and  punctured  Avounds  that  have  not  been  exposed  to  irritating 
or  septic  influences  may  heal  in  the  course  of  twenty-four  hours.  As  a  rule, 
however,  from  five  to  seven  days  are  required  before  the  falling  of  the  crust 
announces  the  comxpletion  of  the  healing  process. 

Even  considerable  losses  of  substance  in  the  skin,  particularly  if  extending 
only  to  the  rete  Malpighii,  may  be  completely  repaired  in  a  very  short  time; 


WOUNDS  3 

the  hemorrhage  being  very  slight  in  these  cases,  the  effused  blood  dries  rapidly, 
and,  under  the  protection  of  the  crust  thus  formed,  cicatrization  is  soon 
complete. 

Healing  by  Secondary  Intention,  i.  e.,  with   Suppuration.— In  a 

^^•idel^'  gaping  wound  the  extent  of  the  injury  and  the  size  of  the  coagulum 
may  prevent  rapid  drying.  In  the  absence  of  preventive  measures  there  are 
present  all  the  conditions  fa\-orable  to  the  implantation  and  reproduction  of 
septic  organisms,  namely,  (1)  organic  tissues  deprived  of  their  protecting 
cuticle;  (2)  a  favorable  temperature  (blood-heat) ;  (3)  moisture.  In  trivial 
incised  wounds  the  surface  of  the  coagulum  dries  cpickly,  and  septic  organ- 
isms are  thus  deprived  of  that  moisture  which  is  absolutely  essential  to 
their  growth;  but  in  the  case  of  large  gaping  wounds  desiccation  cannot 
take  place  rapidly;  as  a  result  bacteria  quickly  multiply  therein,  and  decay 
and  disorganization  of  tissue  take  the  place  of  repair.  Under  these  circum- 
stances in  the  course  of  twenty-four  hours  the  wound  is  covered  with  a  semi- 
liquid,  foul-smelling  layer  of  broken-down  tissue  swarming  with  the  organisms 
of  putrefaction.  Peculiar  changes  due  to  a  local  sepsis  or  infection  occur  also  in 
the  neighborhood  of  the  wound.  A  more  or  less  broad  zone  of  redness  appears 
about  the  edges,  together  with  increased  heat  and  subsequent  induration,  and 
the  patient  complains  of  pain  and  a  feeling  of  tension  in  the  surround- 
ing tissues.  These  symptoms  increase  as  putrefaction  of  the  coagulum  pro- 
gresses. In  some  contused  wounds  a  foul-smelling,  semiliquid  mass  exudes 
from  beneath  the  lacerated  edges,  mingled  with  the  debris  of  broken-down 
tissue.  If  improvement  occurs,  a  yellowish-white  and  creamlike  secretion 
makes  its  appearance  over  the  edges  of  the  wound  about  the  fifth  day,  and  the 
"laudable  pus"  of  the  older  surgery  is  present.  With  the  cessation  of  the 
so-called  ichorous  discharge  the  wound  enters  on  the  stage  of  suppuration. 

With  the  advent  of  suppuration  there  is  a  diminution  of  the  redness,  heat, 
swelling,  and  pain  which  are  the  classic  symptoms  of  an  inflammatory  process. 
The  length  of  time  covered  by  the  stages  of  suppuration  varies  with  the  depth 
of  the  wound,  the  extent  of  the  laceration  of  its  edges  and  the  contusion  of  sur- 
rounding parts  In  an  uncomplicated  lacerated  wound ,  from  about  the  seventh 
day  there  is  observed  a  mass  of  material  of  pinkish  hue  which  forms  beneath 
the  layer  of  pus  and  rises  from  the  depths  of  the  wound.  This  consists  of 
small  papillae  which  continue  to  rise  higher  and  higher  until  they  fill  in  the 
entire  ^^•ound  cavity,  so  that  its  surface  presents  a  granular  appearance.  The 
wound  is  then  said  to  be  "granulating,"  and  the  papillae  are  called  "granu- 
lation tissue."  The  presence  of  granulations  constitutes  another  stage  in 
the  process  of  repair. 

The  parts  surrounding  the  wound  at  this  time  return  nearly  or  quite  to  their 
normal  condition.  Redness  and  heat  disappear,  and  tenderness,  with  per- 
haps some  induration,  alone  remains  to  indicate  that  the  reparative  process 
is  still  going  on  in  the  depths  of  the  wound.  As  the  cavity  of  the  wound 
becomes  filled  with  granulation  tissue  the  latter,  which  up  to  this  time  has 
been  more  or  less  easily  injured  and  has  bled  at  the  slightest  touch,  becomes  to 
some  extent  solidified,  loses  its  bright  pink  color,  and  grows  pale.  At  the  same 
time  a  process  of  shrinkage  goes  on,  and  in  a  corresponding  degree  the  cavity 
of  the  wound  markedlv  diminishes. 


4  INFLAMMATION 

AVhen  the  granulating  surface  is  level  with  the  surrounding  surfaces,  a  nar- 
row strip  of  new  epidermis  begins  to  grow  around  the  edges  of  the  wound,  and 
increases  from  without  inward.  One  zone  after  another,  growing  concentric- 
ally, is  added  to  the  new  tissue  until,  when  they  meet  in  the  middle,  the  new 
epidermis  comi^letely  covers  in  the  granulating  surface  and  cicatrization  is 
accomplished. 

The  two  processes  of  healing  thus  briefly  described  have  been  recognized 
for  years,  but  it  was  not  until  John  Hunter  (1793)  pursued  his  classic 
studies  on  the  subject  that  these  processes  were  fully  recognized  and  distin- 
guished as  healing  by  primary  and  by  secondary  intention. 

Healing  by  first  intention  seems  almost  a  ph^'siologic  process,  inasmuch 
as  it  is  the  simplest  and  most  direct  method  of  repairing  tissues  lost  or  destroyed. 
In  some  of  its  stages  it  seems  to  be  akin  to  the  processes  of  restitution  of 
epithelial  tissues  constantly  going  on  as  normal  metamorphosis,  if  indeed  it  is 
not  entirely  identical  with  them. 

In  the  second  method  of  I'epair,  healing  by  second  intention,  the  reproduc- 
tion of  tissue  in  connection  Avith  suppuration  is  marked  by  the  presence  of  true 
inflammatory  conditions,  the  essential  and  characteristic  symptoms  of  which 
have  been  knowTi  since  the  days  of  Galen,  namely,  (1)  redness  (rubor) ; 
(2)  local  heat  (calor) ;  (3)  swelling  (tumorj ;  (4)  pain  (dolor).  To  these 
is  to  be  added  (o)  interference  with  the  function  of  the  part  (functio  laesa). 

Histology  of  the  Healing  Process. — Such  a  thing  as  immediate  union 
after  the  infliction  of  a  wound  does  not  occur,  if  by  this  is  meant  the  direct 
adhesion  of  the  histologic  elements  of  the  parts,  without  further  reparatii^e 
effort.  Trabeculae  form  in  the  exuded  fibrin,  making  up  a  fine  network  from 
which  processes  are  sent  out  into  the  open  blood-vessels  and  into  the  clefts  or 
spaces  between  the  tissues.  In  the  cavit}"  of  the  wound  itself,  however,  there 
will  be  found,  besides  blood-corpuscles,  small  portions  of  necrotic  tissue  and 
coagulated  fibrin.  The  blood-corpuscles  are  partly  unchanged.  Some,  how- 
ever, have  assumed  a  star-shaped  appearance,  while  others  are  swollen  and 
pale  in  color.  The  passage  of  the  trabeculae  of  the  coagulum  into  the 
mouths  of  the  open  blood-vessels  leads  to  coagulation  in  the  neighboring 
capillaries.  In  from  twenty-four  to  forty-eight  hours  the  red  blood-corpus- 
cles have  almost  entirely  disappeared.  Those  ^vhich  remain  have  lost  their 
color  and  have  become  diaphanous  or  finely  granulated.  The  spaces  now  found 
in  the  network  mark  the  site  of  former  blood-corpuscles  which  have  been 
destroyed.  Simultaneously  with  the  disappearance  of  the  red  blood-corpuscles, 
the  so-called  cells  of  new  formation  make  their  appearance.  These  are  small 
round-cells  with  a  clear  nucleus,  which  in  size  and  general  appearance  resemble 
the  young  cells  of  connective  tissue  as  well  as  the  colorless  blood-corpuscles  them- 
selves. These  gradually  fill  up  the  gap  in  the  wounded  structures,  and  in  addi- 
tion are  crowded  into  the  neighboring  perivascular  spaces.  About  the  fourth 
clay  blood-vessels  in  small  loops  pass  from  the  edges  of  the  wound,  and  meeting 
in  the  center  anastomose  or  unite  in  the  new  cellular  mass  (Julian 
Arnold).  These  vessels  are  the  result  of  a  process  of  proliferation. 
A  slight  granular  thickening  on  the  wall  of  a  capillary  marks  the  point  whence 
a  new  vessel  is  about  to  bud.  This  projects  in  a  somewhat  triangular  shape, 
and  is  the  so-called  protoplasmic  proliferation.  The  projection  develops  into 
a  fine  cord  with  a  threadlike  termination,  becomes  hollow  at  the  base,  and 


WOUNDS  5 

blood  enters  it  from  the  parent  vessel.  F)>-  the  uniori  of  these  protoplasmic 
cords  an  arch-shajjed  connection  is  established  between  two  capillaries,  con- 
stituting the  so-called  protoplasmic  arch.  In  the  beginning  this  contains  blood 
only  in  the  hollow  base,  but  a  process  of  canalization  takes  place  in  the  inter- 
mediate portion  and  later  complete  conmiunication  is  established.  These  pro- 
toplasmic arches  are  at  first  homogeneous,  but  a  nucleated  structure  subse- 
quently replaces  the  homogeneous  connection,  and  they  become  lined  with 
endothelium.  Later,  by  a  process  of  cleavage  new  cellular  elements  develop 
and  new  capillary  vessels  are  formed  from  the  condensed  cellular  bodies.  This 
primary  cellular  layer  is  enlarged  from  within  by  the  adjacent  round-cells  of 
new  formation  (formative  cells  of  Ma  re  hand),  which  latter  form  the 
adventitia  of  the  new  vessels. 

Thiersch  carefully  injected  tissues  undergoing  reparati\-e  processes 
and  microscopically  examined  sections  of  the  same.  He  believed  that  spaces 
existed  betAveen  the  connective-tissue  new-formation  cells  and  that  the  injected 
fluid  passed  into  these  from  the  blood-vessels ;  on  the  basis  of  these  experiments 
he  assumed  that  there  was'  a  system  of  intercellular  canals  communicating 
directly  with  the  vessels  whose  function  was  to  supply  nutriment  to  the  parts 
until  new  blood-vessels  were  formed.  It  is  extremely  difficult  at  the  present 
time  to  decide  whether  such  a  system  of  plasma  canals  really  exists  or 
whether  Thiersch's  injections  penetrated  simply  into  the  protoplasmic 
arches  and  the  proliferations  of  the  vessels  of  Arnold. 

The  formative  round-cells  which  fill  the  wound  soon  begin  to  undergo  trans- 
formation. The  intercellular  spaces  increase,  and  between  them  there  grows  a 
framework,  partly  striped,  partly  granular,  which  in  all  probability  originates 
in  the  cells  themselves.  At  a  still  later  stage  of  development  the  striped 
appearance  of  the  intercellular  substance  becomes  more  clearly  defined,  eventu- 
ally developing  into  fine  fibers,  between  which  are  found  spindle-cells,  perhaps 
the  remains  of  the  masses  of  round-cells. 

With  the  disappearance  of  the  round-cells  and  the  appearance  of  the  newly 
formed  fibers  the  new  tissue  closely  resembles  3'oung  connective  tissue.  As 
cicatrization  goes  on,  the  spindle-cells,  as  well  as  the  round  or  formative  cells, 
vanish,  some  undergoing  granular  degeneration  and  absorption  while  others 
are  either  taken  up  again  by  the  circulation,  or,  after  reaching  a  certain  stage 
of  development,  destroyed  by  cell  action  in  the  process.  The  shelter  of  the 
•  epidermis  is  now  needed  to  complete  repair.  On  the  surface  of  the  built-up 
tissues  a  clot  or  crust  consisting  of  broken-down  blood-corpuscles,  epithehal 
scales,  and  exudation  forms,  and  beneath  this  new  epithelium  develops,  which 
the  rete  JMalpighii  of  the  adjoining  skin  furnishes.  Its  cells  are  increased  by 
nuclear  segmentation,  and  these  new  cells  arrange  themselves  along  the  young 
connective  tissue  until  they  meet  and  finally  cover  in  the  surface  of  the  wound. 

The  histologic  process  which  marks  the  healing  of  a  wound  by  second  inten- 
tion (healing  by  suppuration)  is  essentially  the  same.  Here  also  after  a  few 
hours  the  round-cells  appear.  When  brought  in  contact  with  the  putrid  blood, 
they  rapidly  perish  and  mingle  with  the  foul  secretions  of  the  wound.  ]\Iicro- 
scopically  at  this  time  the  discharge  during  the  first  three  days  consists  of  por- 
tions of  fibrin,  red  blood-corpuscles  in  different  stages  of  decomposition,  granu- 
lar detritus,  bacteria,  and,  finally,  of  dead  connective-tissue  cells  that  undergo 
changes  in  c|uality  and  form  the  principal  components  of  pus.     From  the 


6  IXFLAM.MATIOX 

surface  of  the  wound,  however,  while  numerous  connective-tissue  cells  arc 
being  thrown  off,  new  ones  are  being  supplied  to  take  their  places,  until  the 
lowest  layer,  being  gradually  supplied  with  blood-vessels,  remains  to  form  the 
young  connective  tissue.  This,  with  its  numerous  loops  of  vessels,  each  sur- 
rounded by  a  growth  of  the  same  connective-tissue  cells,  appears  as  a  surface 
of  light  and  irregular  nodules,  the  granulations.  The  discharge  of  pus  gradu- 
ally lessens.  No  disturbing  influence  interfering,  the  granulation  tissue  gradu- 
ally fills  up  the  cavity,  and  its  size  is  diminished  also  by  a  general  shrinkage 
of  the  whole  mass.  Finally,  as  the  wound  surface  becomes  level  A^ith  the  sur- 
rounding integument,  cicatrization  is  completed  by  the  renewal  of  the  pro- 
tective epidermis,  as  before  described.  As  a  rule,  the  new  epidermis  forms  a 
narrow  zone  about  the  edges  of  the  wound,  but  occasionally  little  islets  spring 
up  at  varying  distances  from  the  margins  themselves,  to  become  the  centers  of 
successive  zones  of  new  epidermis.  The  latter  may  originate  from  the  cells 
surrounding  the  sweat-glands  and  hair-follicles,  which,  passing  as  they  do  deeply 
into  the  cutis,  may  have  escaped  injuiy,  even  in  wounds  involving  considerable 
loss  of  substance.  Again,  it  may  occur  during  changes  in  dressings,  or  in  some 
other  way,  that  epidermal  cells  may  be  sown  over  the  granulation  tis.sue,  trans- 
planted, as  it  were,  from  sound  skin.  It  has  likewise  been  suggested  that  a 
narrow  epithelial  strip  may  extend  from  the  margin  of  the  wound  to  the  islets. 
Ho\\ever  this  ma}-  be,  it  is  not  at  all  probable  that  these  epithelial  cells  are 
formed  from  the  round-cells  of  the  granulation  tissue. 

An  additional  division  of  the  subject  is  made  by  some  writers,  the  so-called 
"healing  by  third  intention."  In  granulating  w^ounds  rendered  aseptic  and 
maintained  so,  direct  union  is  said  to  take  place,  if,  after  the  lapse  of  two  or 
three  days,  or  when  the  granulating  process  is  well  under  way  and  there  is  but 
little  or  no  secretion  present,  the  granulating  surfaces  are  brought  into  apposi- 
tion. The  histologic  process,  however,  differs  in  nowise  from  the  foregoing. 
Septic  conditions  are  replaced  by  an  aseptic  state,  and  the  gap  to  be  filled  is 
simply  lessened  by  mechanical  means. 

The  question  of  the  origin  of  the  connective-tissue  cells  during  the  heal- 
ing process  has  received  a  great  deal  of  attention.  It  was  formerly  supposed 
that  the  spindle-shaped  corpuscles,  the  only  cells  then  knoA^Ti  to  exist  as  con- 
nective-tissue cells,  were  the  progenitors  of  the  round-cells.  The  origin  of  this 
belief  seems  to  be  the  observation  previously  made  that  in  fetal  connective 
tissue  spindle-cells  developed  from  the  round-cells  lying  in  large  numbers  in 
the  matrix.  In  1863  Recklinghausen,  in  the  course  of  experi- 
ments on  the  corneas  of  rabbits  and  frogs,  found,  in  addition  to  the  so-called 
fixed  corneal  corpuscles,  small  round-cells  which  possessed  the  peculiar  property 
of  changing  their  form  and  position  in  a  manner  entirely  independent  of  one 
another.  They  bore  a  striking  resemblance  to  the  round-cells  of  pus,  as  well 
as  to  the  Avhite  blood-corpuscles.  C  o  h  n  h  e  i  m  ,  in  1867,  demonstrated 
the  direct  origin  of  the  migrating  cells  from  the  blood.  The  mesentery  of  the 
frog  was  usecl  for  the  experiment,  and  the  white  blood-corpuscles  were  obserA^ed 
to  escape  through  the  uninjured  wall  of  the  vessel  into  the  perivascular  connec- 
tive-tissue spaces  (diapedesis).  Thoma  (1878)  succeeded  in  demonstrat- 
ing in  the  exposed  mesentery'  of  the  dog  (1)  the  dilatation  of  the  vessels  and  the 
retardation  of  the  blood-current;  (2)  the  adhesion  of  the  white  blood-corpus- 
cles to  the  walls  of  the  capillaries :  (3)  the  passage  of  the  corpuscles  through  the 


AVOUXDS 


walls  of  the  vessels.  The  query  as  to  whether  all  the  pus  present  in  a  case  of 
prolonged  suppuration  can  be  accounted  for  by  C  o  h  n  h  e  i  m  '  s  theory  of 
diapedesis  is  an  interesting  one.  There  are  to  be  accounted  for,  in  addition, 
the  round-cells,  the  newly  formed  blood-vessels,  their  walls  first  homogeneous 
and  then  nucleated,  the  young  connective  tissue,  and  the  granulation  structure. 
Do  these  all  originate  from  the  white  blood-corpuscles  ?  While  the  adversaries 
of  the  exclusi\-e  diapedesis  theory  asserted  that  corpuscles  of  connective  tissue, 
as  well  as  endothelial  cells,  underwent  a  contractile  change  of  shape  and  division, 
C  o  h  n  h  e  i  m  and  his  followers  combated  this  with  the  classic  experi- 
ments with  cinnabar.  The  blood  of  frogs  was  injected  with  cinnabar,  the  finely 
di^■ided  particles  of  which  were  readih'  absorbed  by  the  white  blood-corpuscles. 
This  furnished  a  method  of  distinguishing  them  from  other  cell-elements  for 
which  they  might  be  mistaken.  The  frog,  after  the  injection,  was  injured,  and 
at  the  site  of  the  injury  could  be  seen  escaping  the  white  blood-corpuscles 
inclosing  the  particles  of  cinnabar.  The  value  of  this  experiment  as  conclusive 
proof  of  the  theoiy  of  diapedesis  is  impaired,  as  is  justh-  remarked  by 
Recklinghausen,  on  account  of  the  well-known  fact  that  the  particles 
of  cinnabar  may  escape  directly  into  the  tissues  from  the  blood-vessels  of  frogs 
so  injected  and  impart  their  stain  to  cells  formed  outside  the  vessels. 

Experimental  research  on  animals  and  obser^'ations  in  man  have  thus 
far  determined  of  inflammation  as  follows:  That  it  consists  in  (1)  dila- 
tation of  blood-vessels;  (2)  increase  in  the  'permeability  of  the  walls  of  the  blood- 
vessels; (3)  augmented  supply  of  nutriment  to  the  tissues;  (4)  migration  of  white 
blood-corpuscles  through  the  vascidar  loalls  into  the  surrounding  connective- 
tissue  spaces.  In  addition,  there  also  probably  occurs  (5)  proliferation  of  pre- 
existing cells.  Finally,  under  certain  circumstances  processes  of  degeneration 
and  decomposition  take  place,  resulting  in  more  or  less  loss  of  tissue. 

This  histologic  definition  of  the  process  of  inflammation  corresponds  through- 
out to  the  clinical  picture.  The  local  results  of  the  morbid  processes  vary  with 
their  intensity  and  extent.  In  other  words,  the  varieties  of  inflammation  are 
due  to  differences  in  the  factors  thereof.  In  indi^'idual  cases  the  four  car- 
dinal symptoms  of  Galen,  redness,  heat,  swelling,  and  pain,  do  not 
coexist  in  the  same  degree. 

The  redness  of  the  inflamed  part  is  the  consequence  of  the  dilatation  of 
the  vessels,  and  results  from  a  paralysis  of  the  muscular  coat.  This  is  due  to 
an  immediate  disturbance  either  of  the  cells  in  the  muscle-fibers  themselves, 
or  of  the  vasomotor  nerves  supplying  them.  At  the  very  outset  this  is  the 
exclusive  cause  of  the  redness,  but  later  on  it  is  further  due  to  the  occurrence 
of  a  stasis  in  the  capillaries  which  leads  to  local  accumulation  of  red  blood- 
corpuscles,  and  finaUy  to  a  formation  of  new  blood-vessels  as  well,  provided  the 
inflammation  persists. 

Increased  heat  in  the  inflamed  part  is  due  to  the  increased  amount  of 
blood  which  the  dilated  capillaries  supply  to  the  tissues;  in  addition,  there 
are  probably  some  chemic  processes  to  be  taken  into  account  (such  as  increased 
oxidation) ,  but  to  what  extent  it  is  difficult  at  present  to  decide. 

The  swelling  of  the  inflamed  tissue  depends  on  the  same  causes,  and,  in 
addition,  on  an  increase  in  nutritive  material  supplied  by  the  escape  of  the 
white  blood-corpuscles  from  the  capiflaries  into  the  connective-tissue  spaces, 
as  well  as  on  the  proliferation  of  the  connective-tissue  cells  themselves. 


8  INFLAMMATION 

Pain  felt  at  the  seat  of  inflammation  is  to  be  referred  to  an  irritation  of  the 
sensory  nerves  of  the  part  and  the  amount  of  pressure  exercised  on  them 
by  the  dilated  blood-vessels  and  the  products  of  inflammation.  The  \-arying 
character  of  the  pain  is  caused  in  part  by  the  varying  force  of  the  blood-current, 
in  part  by  the  occurrence  of  congestion  in  dependent  parts,  and  to  some  extent 
by  the  resistance  which  the  tissues  offer  to  the  increase  of  nutrient  material 
and  to  the  products  of  inflammation. 

INFLAMMATION  IN  GENERAL 

The  reparative  process  already  considered  consists,  first,  of  that  in  \A'hich 
the  loss  of  the  essential  tissue  elements  is  immediately  replaced;  second, 
of  that  in  which  the  repair  is  accomplished  by  the  slower  and  more  tedious 
process  of  suppuration.  In  the  first  case  the  cellular  material  for  repair  is  at 
once  appropriated  to  its  uses  without  waste,  with  the  co-operation  of  the  adja- 
cent vessels  and  without  disturbance  of  neighboring  structures.  In  the  second, 
the  putrid  decomposition  of  the  extravasated  blood  and  the  exposed  tissues 
is  followed  by  a  copious  outpouring  of  blood-plasma  and  white  blood-corpuscles, 
which  inundates  the  wound  with  formative  material.  Here,  however,  everything 
is  exposed  to  putrefaction  and  decay,  and  the  decomposed  products  of  destroyed 
tissue  rapidly  cause  tissues  previoush^  healthy  to  become  involved  in  the  local 
death.  These  two  processes  correspond  to  two  forms  of  inflammation,  and 
have  been  called  resi3ectively  the  regenerative  and  the  destructive.  Where 
the  process  involves,  however,  the  formation  of  a  new  tissue  which  cannot  be 
said  to  represent  strictly  the  regenerative  process,  but  substitutes  for  the  lost 
tissues  material  which  may  be  classed  as  superfluous,  this  is  known  as  the  pro- 
ductive form  of  inflammation.  The  exudative  form  is  characterized  by  a 
predominating  and  persistent  exudation  of  blood-plasma  from  the  tissues,  the 
migration  of  the  colorless  blood-corpuscles  or  leukocytes  being  less  marked 
than  in  the  other  forms. 

The  regenerative  form  of  inflammation  is  that  which  occurs  in  every  case 
of  primar\^  union.  It  like^^ise  concludes  the  process  of  destructive  inflamma- 
tion whenever  the  latter  tends  to  resolution,  and  invariabl^v  furnishes  the 
material  for  building  up  the  cicatrix. 

The  productive  form  of  inflammation  will  be  referred  to  in  the  discussion 
of  diseases  of  separate  structures  as  adhesive  or  hyperplastic.  It  not  infre- 
cjuently  accompanies  the  regenerative,  or  closes  the  destructive  form. 

The  exudative  variety  appears  as  the  serous,  serofibrinous,  and  sero- 
hemorrhagic. Finally,  w^e  recognize  four  varieties  of  the  destructive  inflam- 
mation, namely,  the  suppurative,  the  purulent,  the  gangrenous,  and  the 
granulating.  These  terms  are  applied  according  as  one  or  the  other  of  the 
conditions  which  they  describe  predominates.  Sharply  defined  distinction 
between  them  cannot  be  made,  however,  because  the  suppurative  may  change 
to  the  purulent  or  the  gangrenous,  the  granulating  to  the  suppurative  form, 
or  vice  versa.     In  fact,  the  four  varieties  are  interchangeable. 

Exudative  Inflammation. — The  lowest  form  of  the  exudative  inflam- 
mation is  the  serous.  In  the  present  state  of  our  knowledge  it  is  presumed 
that  this  form  is  the  result  of  noxious  agents  whose  influence  on  the  vessels 
is  neither  of  a  verv  intense  character  nor  of  long  duration.     Its  most  promi- 


INFLAMMATION    IN    GENERAL  9 

nent  characteristic  is  an  increased  secretion  of  fluid  which  distends  the  connec- 
tive-tissue spaces.  This  is  foflowed  by  flat  swellings  of  the  soft  parts,  which, 
on  palpation,  feel  dough}-  and  can  be  made  to  diminish  or  to  disappear  alto- 
gether by  pressure.  Should  the  serous  exudation  occur  in  the  rete  Malpighii, 
the  epidermis  is  elevated  at  one  or  more  points,  and  blisters  or  blebs  result. 
When  this  form  of  inflammation  attacks  mucous  membrane,  the  exudation 
becomes  mingled  with  the  mucous  secretion  and  thins  it,  so  that  a  mixture  of 
the  two  or  a  seromucous  discharge  is  the  result.  In  serous  and  synovial  cavi- 
ties the  occurrence  of  this  form  of  inflammation  sometimes  leads  to  enormous 
accumulations  of  fluid  and  occasional  displacements  of  neighboring  organs, 
as,  for  instance,  in  the  chest  when  the  pleural  cavities  are  involved,  or  in  a 
hydrarthrosis  of  the  knee-joint  with  a  resulting  deformity.  The  term  inflam- 
matory edema  is  sometimes  applied  to  this  form  of  exudative  inflammation. 
It  should  not,  however,  be  confounded  with  ordinary  edema,  the  result  of 
mechanical  obstruction  to  the  circulation.  It  may  be  difficult  to  discriminate 
between  the  t^^•o,  but  it  should  be  borne  in  mind  that  the  former  is  character- 
ized by  the  occurrence  of  fibrin  in  the  exudation  together  with  an  occasional 
white  blood-corpuscle,  and  is  a  true  inflammation.  In  simple  edema,  however, 
the  mechanical  obstruction,  while  permitting  the  ingress  of  blood  through  the 
elastic  capillaries,  prevents  its  egress  through  the  more  readily  collapsed  veins. 
As  a  consequence  of  this  passive  engorgement,  the  serum  of  the  blood  escapes 
through  the  distended  vessel  walls  into  the  surrounding  connective- tissue  spaces. 
The  fluid  which  thus  collects  contains  Ixit  little  fibrin.  The  difficulty  of  dis- 
tinguishing between  these  two  conditions  may  be  increased  by  the  fact  that 
\'enous  obstruction  may  complicate  the  inflammation  and  give  rise  to  passive 
edema  in  addition. 

Serofibrinous  inflammation  is  a  serous  inflammation,  which,  occurring 
in  serous  or  synovial  cavities,  is  characterized  by  a  deposit  of  fibrin  on  the 
walls  of  the  cavity.  Sometimes  the  fibrin  is  present  in  the  form  of  flakes 
floating  in  the  fluid  effusion.  Here  the  fibrin  has  become  coagulated  and  is 
precipitated.  How  far  the  various  agents  that  induced  the  inflammation  in 
the  first  place  contribute  in  the  furnishing  of  a  fibrin  ferment  is,  in  the  present 
state  of  our  knowledge,  a  matter  of  speculation. 

Serohemorrhagic  inflammation  is  that  variety  characterized  by  the  addi- 
tion, to  a  greater  or  lesser  extent,  of  red  blood-corpuscles  to  the  serous  effu- 
sion. The  secretion  of  a  serous  or  synovial  cavity  may  thus  be  stained  red, 
like  blood.  The  contents  of  a  bleb  or  blister  sometimes  in  like  manner 
becomes  colored.  OccasionaUy  a  condition  is  observed  which  simulates  that 
just  described.  It  consists  of  a  collection  of  blood-corpuscles  outside  the 
vessels,  and  is  due  to  an  extensive  obstruction  of  the  blood-current,  a  stasis 
in  a  circumscribed  capillary  area.  Here  the  vessels  are  crowded  Avith  red 
blood-corpuscles  which,  as  the  result  of  pressure,  pass  through  the  dilated 
vessels  singly  or  in  groups.  This  process  is  simply  mechanical  and  passive, 
and  is  known  as  hemorrhagic  diapedesis. 

In  exudative  inflammation  there  is  generally  an  intrinsic  tendency  to 
recovery.  A  complete  return  to  the  normal  is  the  rule.  Even  though  large 
amounts  of  exudative  material  ha^-e  been  poured  out  into  the  connective-tissue 
spaces,  this  is  soon  taken  up  by  the  lymph-channels  and  no  lesion  demonstrable 
to  the  eye  is  left.     It  occasionally  happens,  however,  particularly  after  inflam- 


10  INFLAMMATION 

mations  of  large  synovial  closed  sacs,  as,  for  instance,  that  of  the  knee-joint, 
that  a  condition  of  recurrent  or  chronic  inflammation  supervenes  and  more  or 
less  of  the  secretion  remains.  In  consec|nence  of  the  access  of  new  noxious 
agents,  the  exudative  form  of  inflammation  is  sometimes  converted  into  the 
suppurative  or  the  purulent  variety.  From  influences  not  at  present  well 
understood  there  may  likewise  occur  a  development  of  the  adhesive  or  hyper- 
plastic form. 

Suppurative  and  Gangrenous  Inflammations. — The  most  important 
form  of  inflammation  from  the  standpoint  of  the  surgeon  is  that  known  as  the 
suppurative.  Its  peculiar  and  distinctive  feature  is  the  presence  of  pus.  The 
most  essential  components  of  pus  are  pus-corpuscles  and  pus-serum.  The 
former  are  for  the  most  part  the  migratory  white  blood-corpuscles,  reinforced 
by  the  proliferations  of  pre-existing  tissue  cells.  Degeneration  and  decay  seem 
to  be  necessary  concomitants  of  pus-corpuscles.  Subsequent  to  their  escape 
into  the  perivascular  spaces,  they  soon  lose  their  characteristics  as  elements 
of  the  blood  and  differ  essentially  from  those  leukocytes  still  in  the  vessels. 
They  are  polynuclear.  This  at  one  time  was  supposed  to  be  proof  of  the 
ability  of  pus-corpuscles  to  proliferate,  but  is  now  recognized  as  an  evidence 
of  degeneration.  Their  nuclei  are  pale,  often  hardly  visible.  The  protoplasm 
is  granular  and  contains  drops  of  fat.  Pus  itself  is  a  yellowish-white  fluid  of 
the  consistency  of  milk  or  cream.  Its  specific  gravity  is  about  1030.  It  is  at 
first  slightly  acid,  but  afterward  becomes  alkaline  by  a  process  of  decomposition 
in  the  course  of  which  ammonia  develops.  When  allowed  to  stand  it  separates 
into  a  sediment  averaging  from  10  to  16  per  cent  of  the  whole  amount,  and  a 
clear  supernatant  fluid  known  as  pus-serum. 

As  a  rule,  pus  is  nearly  odorless.  The  sediment  consists  of  the  pus-corpus- 
cles, pyogenic  organisms,  and  fragments  of  broken-down  tissue.  Pus-serum 
is  a  pale,  yellowish  fluid  corresponding  to  the  blood-plasma  which  has  left  the 
vessels,  from  which,  however,  it  often  differs  in  chemic  composition  in  addition 
to  containing  the  products  of  the  decomposition  of  tissues  during  the  suppura- 
tive process,  such  as  leucin  and  tyrosin. 

Oxygen  and  hydrogen  are  absent  from  pus-serum,  but  nitrogen  and  carbon 
dioxid  are  always  present.  The  proportion  of  potassium  and  sodium  salts  is 
somewhat  larger  than  in  blood.  Among  the  albuminous  substances  found 
in  pus-serum  may  be  mentioned  paraglobulin,  an  albuminate  resembling  casein 
but  not  precipitated  by  rennet,  serum-albumin,  and  myosin.  In  addition  to 
the  constituents  of  pus  already  mentioned,  occur  flakes  of  coagulated  fibrin, 
red  corpuscles,  and  the  rhombic  plates  of  cholesterin.  The  last  is  found  only 
in  pus  which  has  been  for  a  long  time  inclosed  in  the  living  body.  Rapidly 
advancing  inflammation  produces  not  rarely  complete  stasis  and  coagulation 
of  the  blood  in  isolated  capillars'  areas,  or  even  in  the  smaller  arterial  vessels. 
Under  these  circumstances,  unless  blood  is  supplied  by  coflateral  branches, 
large  portions  of  tissue  are  liable  to  die,  and  as  a  consequence  we  have  local 
death  or  gangrene.  At  the  margin  of  this  dead  tissue,  and  maintained  by  it, 
there  is  a  zone  of  suppuration  which  circumscribes  and  isolates  it,  and  the  whole 
process  constitutes  what  is  kno^^^l  as  suppurative  gangrenous  inflammation. 

The  extent  to  which  tissues  become  necrotic  does  not  always  depend  on 
the  degree  or  intensity  of  the  inflammation  present,  but  rather  on  the  pre- 
vious vitalitv  of  the  structure  involved.     This  is  illustrated  by  the  compara- 


INFLAMMATION    IN    GENERAL  11 

live  behavior  of  tendon  and  muscle.  The  former  will  slough  readily  from  a 
slight  inflammatory  action,  for,  since  it  contains  no  blood-vessels,  but  onh' 
lymph-channels,  the  lymph-channels  become  easily  obstructed  and  the  tendon 
dies,  as  nutrition  is  thus  cut  off  from  it.  The  muscle,  on  the  contrary,  abun- 
dantly supplied  with  blood-vessels,  resists  the  attack  of  the  inflammatory  process 
and  survives. 

The  progress  which  the  inflammation  makes  in  the  healthy  tissues  sur- 
rounding its  focus  depends  partly  on  their  condition,  partly  on  the  force  of 
the  lymphatic  current,  and  perhaps  to  some  extent  on  the  ameboid  move- 
ments of  the  migrating  cells.  The  latter,  if  H  u  e  t  e  r  '  s  observations  are 
correct,  ma}-,  by  virtue  of  the  organisms  that  they  contain,  become  the 
bearers  of  infection. 

The  passive  methods  of  propagation  are  of  the  greatest  importance,  how- 
ever, in  considering  the  spread  of  the  inflammatory  process.  Advancing  sup- 
puration frequently  follows  the  line  of  the  lymphatics,  and  consecjuently 
lymphangitis  is  the  not  infrequent  precursor  of  suppuration.  The  quality  of 
the  surrounding  tissues  is  likewise  to  be  taken  into  account.  I>oose  tissues 
favor  inflammation,  solid  structures  resist  it. 

Phlegmonous  Inflammation. — Phlegmonous  inflammation  is  charac- 
terized by  the  rapidity  ■\\ith  which  it  advances  over  large  areas  of  flattened 
tissue.  It  may  spread  along  the  planes  of  connective  tissue  which  lie  between 
skin  and  fascia,  or  along  the  loose  areolar  tissue  about  the  muscles,  aponeuroses, 
or  tendons.  Phlegmons  such  as  these  are  known  as  subcutaneous  or  sub- 
fascial. Phlegmons  developing  in  special  situations  have  been  designated  by 
special  names,  as,  for  instance,  paronychia  or  panaris  when  they  develop 
in  the  subcutaneous  connectii-e  tissue  of  the  palmar  surface  of  the  fingers. 

Abscess. — Circumscribed  collections  of  pus  in  large  c^uantities  are  termed 
abscesses.  A  characteristic  of  abscess  is  the  progress  of  pus  in  all  directions 
from  the  original  focus  of  infection  with  an  inherent  tendency  to  evacuate 
itself.  This  happens  always  along  the  line  of  least  resistance.  Hence 
abscesses  either  seek  the  surface  or  evacuate  themselves  into  the  cavity  of  some 
hollow  viscus.  It  is  notably  easy  to  distinguish  between  phlegmon  and 
abscess,  although  one  condition  may  readily  pass  into  the  other,  as,  for 
instance,  when  a  spreading  phlegmon  meets  with  a  layer  of  more  solid  and 
resisting  connective  tissue,  and,  thus  circumscribed,  becomes  practically  an 
abscess;  and  vice  versa,  where  an  abscess  slowly  increasing  meets  'uith  a  layer 
of  loose  connective  tissue  and  lights  up  there  a  rapidly  advancing  phlegmonous 
inflammation.  "^^Tiile,  however,  the  phlegmon  always  presents  the  character 
of  an  acute  inflammation,  the  course  of  the  abscess  may  var\''  according  to 
the  susceptibility  of  the  tissues  attacked.  Accordingly  the  abscess  is  distin- 
guished either  as  hot  (acute)  or  as  cold  (chronic). 

The  acute  abscess  is  characterized  by  active  hyperemia,  marked  local  heat, 
and  rapid  destruction  of  tissue.  The  cold  abscess,  on  the  other  hand,  is  accom- 
panied by  ver}^  slight  local  rise  of  temperature,  and  a  comparatively  slow 
progress  of  the  suppurative  process.  The  latter  may,  indeed,  come  to  a  stand- 
still and  remain  in  this  condition  for  a  considerable  time.  It  is  usualh'  of 
tuberculous  origin,  and  may  be  converted  into  an  acute  abscess  if  it  becomes 
infected  by  the  ordinary  pus  organisms. 

An  abscess  cavity  is  usually  surrounded  by  a  zone  of  granulation  tissue, 
which,  whether  the  abscess  is  emptied  by  artificial  means  or  spontaneously, 


12  ,  INFLAMMATION 

is  the  starting-point  of  the  reparative  process.     This  granulation  tissue,  by  its 
augmentation,  gradually  fills  up  the  cavity  formerl}'  occupied  b}-  the  ])us. 

Sinus. — The  final  closure  of  an  abscess  may,  however,  be  retarded  by  one 
cause  or  another.  In  such  an  event  a  communication  is  maintained  between 
the  surface  on  which  the  abscess  discharges  (be  it  skin  or  mucous  membrane) 
and  its  old  cavity,  and  the  latter,  narrowed  doAvn  by  granulation  tissue,  is 
called  a  sinus.  A  sinus  may  also  be  caused  by  the  burro^\•ing  of  the  pus  in 
different  directions,  a  number  of  tortuous  channels  thus  forming.  Such  a 
result  is  more  likely  to  follow  the  spontaneous  opening  of  an  abscess,  though 
it  may  happen  after  an  insufficient  or  ill  placed  incision ;  for  an  opening  which 
does  not  give  free  drainage,  A^'hether  resulting  from  the  natural  process  of  ulcera- 
tion toward  the  surface  (the  so-called  pointing  of  an  abscess),  or  made  by  the 
surgeon's  knife,  will  in  all  probability  lead  to  the  formation  of  a  sinus.  On 
the  other  hand,  a  free  opening  made  so  as  to  afford  a  ready  exit  to  the  contents 
of  the  abscess  offers  the  best  security  against  such  a  result.  The  cavity  of  an 
abscess,  as  it  becomes  filled  up  with  granulations  and  cicatricial  formation, 
gradually  contracts  until  the  external  communication  is  narrowed  down  so  as 
to  admit  a  fine  probe.  This  finally  closes  under  favorable  circumstances;  but 
if  at  the  bottom  of  the  abscess  cavity  there  remains  a  portion  of  necrosed  tissue, 
a  foreign  body  or  necrosed  bone,  though  the  granulations  close  around  it  and 
contraction  takes  place,  there  will  still  be  a  sinus  leading  to  the  offending 
body,  which  will  not  close.  About  the  mouth  of  the  sinus  grows  a  mass  of 
granulations,  rich  in  organisms,  which  presents  a  peculiar  puckered  appearance 
comparable  to  the  anus  of  a  fowl.  Again,  the  cavity  may  fail  to  close  from 
inability  of  its  walls  to  collapse,  as  in  an  empyema  or  a  bone  abscess.  A  dis- 
eased condition  of  the  walls  of  the  sinus  may  also  hinder  complete  healing. 
In  the  case  of  persistent  sinus  due  to  the  presence  of  a  foreign  body,  necrosed 
bone,  etc.,  the  removal  of  the  irritating  cause  is  essential  to  the  closure  of  the 
sinus,  together  with  the  thorough  cureting  of  its  walls. 

Fistula. — Where  an  abscess  opens  into  some  natural  cavity  or  hollow  viscus, 
as,  for  instance,  the  rectum,  vagina,  or  bladder,  or  into  a  natural  canal,  as  the 
urethra  or  Stenson's  duct,  the  resulting  communication  is  called  a  fistula. 
Communications  existing  between  normal  cavities,  as  between  the  bladder 
and  the  vagina,  are  likewise  called  fistulas,  and  are  known  by  special  names 
which  indicate  the  parts  involved.  Thus,  a  fistulous  tract  between  the  blad- 
der and  the  vagina  is  called  a  vesicovaginal  fistula.  These  will  be  described 
under  their  appropriate  names. 

Granulating  Inflammation. — The  formation  of  granulation  tissue  repre- 
sents a  stage  between  suppuration  and  cicatrization.  It  is  the  first  step,  so  to 
speak,  in  the  replacement  of  the  defect  caused  by  the  injur>^  and  subsequent 
suppuration.  There  are  other  kinds  of  inflammation  in  Avhich  the  formation 
of  granulations  precedes  rather  than  follows-  suppuration,  the  latter  occurring 
as  a  secretion  from  the  granulating  surface  itself.  The  inflammation  here  seems 
to  be  due  to  some  interruption  of  the  normal  course  of  the  granulating  process. 
Granulating  inflammation  is  essentially  chronic  in  its  course,  and  occurs  in 
individuals  having  those  peculiar  constitutional  disturbances  formerly  com- 
prehended under  the  name  of  scrofula ;  also  in  those  suffering  from  syphilis, 
etc.  Granulating  inflammations,  unlike  the  serous  and  suppurating  forms, 
are  not  caused  by  common  injuries  involving  the  infliction  of  a  wound  and  the 


INFLAMMATION    IN    GENERAL  13 

entrance  of  air  and  dust,  if,  indeed,  traumatism  enters  into  their  etiolo2;y  at  all. 
They  are  most  likely  to  occur  in  yoiith  and  attack  the  medullary  substance  of 
bones,  the  lymphatic  glands,  tlu^  joints,  or  the  surface  of  the  skin. 

The  differences  between  iiran\ilation  tissue  occurring  in  the  border  zone 
of  an  abscess  and  that  resulting  from  a  granulating  inflammation  are  not  at 
first  ^\•ell  marked.  Both  consist  of  newly  formed  vessels  between  which  are 
fo\uul  the  small,  round,  fixed,  connective-tissue  cells  and  white  blood-corpus- 
cles. Later  on,  however,  the>-  pursue  a  different  course.  The  former  shows 
an  intrinsic  tendency  to  cicatricial  formation,  while  the  latter  seems  predis- 
posed to  prolonged  suppuration;  if  repair  takes  place  at  all,  it  is  long  delayed. 
Abscesses  occur  as  a  sequence  of  the  granulating  inflammation;  these  may 
find  their  wav  singly  to  the  surface,  or  may  unite  to  form  one  large  abscess. 
Here  again  an  apparent  resemblance  may  be  detected  between  this  form  and 
the  common  suppurative  inflammation.  It  is,  however,  an  apparent  resem- 
blance only,  for  in  the  ordinary  suppurative  variety  the  granulating  zone  soon 
shows  a  tendency  to  contract  and  so  close  the  cavity,  but  in  the  granulating 
inflammation  the  granulations  appear  pale  or  faded.  They  become  yellow 
or  gray  toward  the  periphery  and  advance  slowly  into  the  surrounding  con- 
nective tissue.  They  break  down  readily,  and  the  pus  which  results  easily 
undergoes  putrefaction.  The  granulating,  or  rather  ulcerative,  process  may 
extend  in  all  directions,  sinuses  forming  which  lead  along  the  connective-tissue 
planes,  and,  what  is  of  most  importance  to  the  surgeon,  to  the  original  focus 
of  inflammation  (medullary  substance  of  bones,  etc.).  The  clinical  characteris- 
tic of  the  granulating  inflammation,  therefore,  is  the  fact  that  it  does  not  lead  to 
the  formation  of  solid  cicatricial  tissue.  On  the  contrary,  after  the  pus  evacuates 
either  into  the  surrounding  tissues  or  externally  it  continues  to  advance  and  to 
involve  contiguous  stimctures  by  a  process  of  progressive  ulceration.  I'nder  cer- 
tain circumstances  this  form  of  inflammation  is  characterized  by  a  dry  condi- 
tion of  the  parts  rather  than  by  the  secretion  of  pus.  Matters  of  a  grayish- 
yellow  color  and  of  the  consistence  of  soft  cheese  are  found  in  the  ulcerating 
tissues  ;  this  process  is  known  as  the  cheesy  metamorphosis,  and  is  some- 
times called  cheesy  inflammation.  The  albuminoid  (nitrogenized)  substances 
resulting  from  the  breaking  down  of  tissue  seem  to  degenerate  into  a  fatty 
substance  which  contains  many  living  organisms.  This  cheesy  metamor- 
phosis occurs  particularly  in  lymphatic  glands. 

In  granulating  inflammations,  histologically  we  find  small  round-cells,  some- 
times gathered  in  groups  and  often  surrounding  a  large  cell  with  many  nuclei, 
the  so-called  giant-cell,  which  in  turn  is  surrounded  by  a  network  of  capillary 
vessels.  These  collections  resemble  the  tubercles  found  in  cases  of  diffused 
miliary  tuberculosis,  scattered  in  numberless  masses  throughout  the  internal 
organs.  They  were  formerly  belie^■ed  to  be  identical  with  these  tubercles, 
though  local  and  less  dangerous  to  life.  Since  the  discovery  of  the  tubercle 
bacillus  by  Koch,  the  presence  or  absence  of  this  organism  will  decide  as 
to  the  tuberculous  character  of  the  inflammatory  process. 


14  IXFLAMMATIOX 


ETIOLOGY  OF   INFLAMMATION 

Process  of  Putrefaction. — Putrefaction  is  the  disintegration,  in  the 
presence  of  moisture,  of  organic  nitrogenous  matters,  particularly  the  albu- 
minoids, into  their  constituent  parts,  the  nitrogen  uniting  with  the  hydrogen 
to  form  ammonia,  the  carbon  Avith  the  oxygen  to  form  carbon  flioxid.  tho 
hydrogen  with  the  oxygen  to  form  water. 

During  this  process  there  is  developed  an  intermediate  class  of  compounds 
which  resemble  the  vegetable  alkaloids  in  their  chemic  composition  and  are 
powerful  poisons.  From  the  fact  that  certain  substances  of  this  class  were  first 
discovered  in  the  dead  body,  they  have  been  termed  ptomains  (-rw.aa,  a  corpse). 

The  conditions  necessar}-  for  putrefaction  are  the  folio Anng:  (1)  heat  of  a 
moderate  grade;  (2)  moisture;  (3)  certain  agents  competent  to  decompose 
organic  matter  when  brought  in  contact  with  it  and  called,  by  the  generic 
terms,  bacteria,  microbes,  or  microorganisms.  As  early  as  1835  C  a  g  - 
niard-Latour  discovered  in  the  fermentation  of  ^mie  small  globular 
structures,  increasing  partly  by  fission,  partly  by  spores.  Schwann,  in 
1837,  by  a  series  of  experiments  demonstrated  the  existence  of  microorgan- 
isms in  the  air  which,  when  brought  in  contact  with  a  proper  nutrient  medium, 
increase  in  number  and  produce  the  phenomena  of  putrefaction.  He  like- 
wise showed  that  these  microorganisms  are  destroyed  by  heat.  A  year  earlier 
(1836)  Franz  Schultze  made  a  series  of  experiments  whose  object  was 
to  refute  the  doctrine  of  spontaneous  generation,  and  showed  that  air  passed 
through  sulfuric  acid  becomes  sterile. 

Subsequently  Schroder  and  D  u  s  c  h  showed  that  neither  heat 
nor  sulfuric  acid  is  necessary  in  order  to  free  the  air  from  so-called  zymotic 
agents,  simple  filtration  through  loose  cotton  being  sufficient.  This  demon- 
strated the  physical  character  of  the  germs. 

Pasteur's  famous  experiments  (1861)  still  further  simplified  the 
matter.  He  showed  that  not  only  can  air  be  deprived  of  its  power  of  infection, 
but  that  the  agents  inducing  the  fermentative  process  are  not  conveyed  through 
a  fine  glass  tube  if  the  latter  is  bent  in  a  downward  direction,  though  the  air 
enters  freely.  In  other  words,  these  agents,  though  microscopic,  partake  more 
or  less  of  the  physical  properties  of  dust  and  obey  the  law  of  gravitation. 

While,  by  the  series  of  experiments  abave  alluded  to,  it  was  clearly  demon- 
strated that  fermentation  and  putrefaction  are  due  to  the  presence  and  growth 
of  microorganisms,  it  still  remained  to  apply  this  knowledge  to  the  relation 
of  the  process  of  putrefaction  to  inflammation.  L  e  m  a  i  r  e  .  in  1860, 
studied  the  effects  of  coal-tar  preparations  on  the  healing  process  in  the 
light  of  the  Schwann-Pasteur  theor\'  as  to  the  origin  of  wound 
putrefaction.  The  results,  however,  were  neither  satisfactory  nor  conclusive 
enough  to  attract  more  than  passing  notice.  It  was  reserv^ed  for  Joseph 
Lister  to  prove  the  definite  relations  which  existed  between  micro- 
organisms and  inflammation,  and  to  this  now  famovis  surgeon  belongs  the  credit 
of  demonstrating  beyond  the  shadow  of  a  doubt  that  the  presence  and  develop- 
ment of  germ  life  in  wounds  is  the  cause  of  suppuration,  and  that  the  so-called 
wound  secjuels.  inflammation,  septicemia,  pyemia,  er\-sipelas.  etc..  are  due  to 
microorganisms. 


ETIOLOGY    OF    INFLAMMATION  15 

Basing  his  theory  on  ihc^  Avell-known  expenments  of  Schwann, 
S  c  h  r  o  d  (M-  ,  1 )  \i  s  (•  h  ,  and  Pasteur,  he  reasoned  that  if  he  could 
protect  fresh  wounds  from  the  putrefactive  processes  caused  by  the  organisms 
of  putrefaction  shown  to  be  present  in  the  air,  or  could  treat  germs,  which 
might  gain  entrance  into  the  wound,  so  as  to  inhibit  their  growth,  the 
interruption  of  the  healing  process  by  those  accidents  which  were  at  once 
the  scourge  and  opprobrium  of  surgen,^  could  be  prevented.  To  this  end  he 
labored  assiduously,  and  finally  developed  a  method  of  wound  treatment  which 
in  its  beginning  was  intended  only  for  operation  "\\ounds.  The  agent  he  mainly 
emploved  was  carbolic  acid,  at  that  time  the  best-known  antiseptic.  The  sur- 
roundings of  the  intended  wound,  the  instruments,  the  hands  of  the  operator, 
the  sponges  and  dressings,  were  all  treated  ^\"ith  a  solution  of  carbolic  acid. 
The  air  of  the  operating  room  was  filled  with  a  nebulized  spray  of  the  same 
antiseptic. 

The  successes  attained  by  this  method  were  remarkable,  and.  though 
at  first  sharply  criticized,  it  was  finally  adopted  by  the  profession  throughout 
the  world.  As  a  result,  large  gaping  wounds  healed  without  suppuration  and 
by  first  intention,  and  this  became  the  rule  rather  than  the  exception  when 
Lister's  method  was  rigidly  followed.  Proof  trod  on  the  heels  of  proof 
until  the  era  of  antiseptic  surgery  was  fairly  established  in  the  world's  his- 
tory, and  became  unalterably  associated  with  the  name  of  Joseph 
Lister,  to  whom  humanity  owes  a  debt  that  it  can  never  repay. 

AVhile  Ij  i  s  t  e  r  was  pursuing  his  experiments  in  the  Royal  Infirmary 
at  Glasgow,  other  observers  were  following  up  elsewhere  the  discoveries  of 
Schwann  and  apph'ing  them  to  medical  science.  In  1868  C.  H  u  e  t  e  r, 
of  Greifswald,  in  a  case  of  hospital  gangrene,  observed  many  nests  of 
microorganisms;  K  1  e  b  s  ,  in  1871,  described  growths  found  in  the  wound 
and  its  neighborhood  in  cases  of  septicemia  and  pyemia,  and  to  these 
organisms  he  gave  the  name  "microsporon  septicum."  He  further  suggested 
that  these  destroyed  the  tissues  and  induced  suppuration,  and  by  penetrating 
into  the  blood-channels  and  lymph-channels  and  being  thus  transported  to 
different  parts  of  the  body,  set  up  a  similar  process  of  suppuration.  Then 
came  Lister's  announcement  of  the  nonsuppurative  course  of  wounds 
under  carbolic  dressings.  This  confirmed  the  relation  of  pathogenic  organisms 
to  wound  diseases. 

The  microorganisms  may  enter  the  wound  either  from  the  surface  of  the 
patient's  bod}',  from  his  clothing,  or  from  contact  with  dust-laden  and  hence 
germ-laden  air.  Fluids  brought  in  contact  ^\ith  the  wound,  if  not  sterilized, 
may  also  prove  to  be  carriers  of  infection.  The  surface  of  the  vulnerating  body 
may  infect  the  wound  in  the  act  of  inflicting  it ;  so  may  the  surgeon's  knife, 
his  hands,  or  those  of  an  attendant,  if  proper  and  adequate  precautions  have 
been  neglected.  In  short,  infection  may  be  conveyed  to  a  wound  by  contact 
with  any  nonsterile  substance.  Common  air  is  full  of  organisms.  If  a  saucer 
of  perfectly  sterilized  jelly  is  allowed  to  remain  exposed  but  for  a  few  minutes 
to  permit  the  deposit  of  organic  dust,  though  subsequently  protected  from 
contamination,  it  will  in  the  course  of  a  few  hours  show  numbers  of  different 
colonies  of  germ  hfe  growing  on  its  surface.  Certain  of  these  bacteria  are  sure 
to  be  putrefactive  organisms  or  pus-producers,  and  they  soon  decompose  the 
gelatin.     These,  when  deposited  by  the  air  in  an  unprotected  wound,  produce 


16  IXFLAMMATIOX 

the  same  phenomena  of  putrefaction  and  suppuration  as  well.  The  albu- 
minous secretions  of  the  wound,  its  moisture,  and  the  natural  heat  of  the 
part  furnish  all  the  conditions  most  favorable  to  the  multiplication  of  micro- 
organisms and  the  subsequent  de\-elopment  of  putrefactive  processes.  Auto- 
infection  may  then  take  place  from  the  putrid  or  decomposing  secretions. 

The  interesting  question  has  arisen  whether  the  fluids  of  the  body  in  a  nor- 
mal state  do  not  themselves  contain  organisms,  which,  poured  out  with  the 
blood,  lymph,  etc.,  in  the  wound  and  thus  brought  in  contact  with  the  air. 
multiply  and  so  produce  decomposition  independent!}'  of  germ  infection  from 
without.  Many  interesting  experiments  have  been  made  with  the  view  of 
clearing  up  this  point.  Results  widely  cUffering  have  been  obtained  at  the 
hands  of  equally  competent  observers,  so  that  it  is  difficult  to  reconcile  state- 
ments so  at  variance.  B  i  1 1  r  o  t  h  '  s  and  Bur  don-Sanderson's 
experiment  consisted  in  the  rapid  removal  of  portions  of  a  sohd  viscus  of  ani- 
mals and  their  immediate  transference  to  heated  paraffin  which  completely 
enveloped  the  mass  on  cooling.  These  underwent  putrefaction  at  about  the 
usual  time.  Xo  provision  was  made  against  the  contact  of  air  with  the  tissues 
when  in  transit,  however,  and  no  matter  ho^^■  quickly  they  might  have  been 
removed,  infection  was  nevertheless  possible.  On  the  other  hand,  carefr.lh- 
conducted  experiments  in  the  hands  of  Pasteur,  Koch,  C  h  e  y  n  e 
and  others  have  pretty  conclusively  proved  that,  as  a  rule,  the  blood  and  tis- 
sues of  a  healthy  body  are  free  from  microorganisms.  Nevertheless  the  bodv 
may  appear  to  be  healthy  and  yet  contain  bacteria.  Klebs,  after 
he  had  made,  with  negatii-e  results,  quite  a  number  of  carefully  conducted 
experiments  on  dogs,  found  microorganisms  in  an  animal  apparently  in  per- 
fect health.  Investigation,  however,  revealed  that  this  identical  animal  had 
been  the  subject  of  a  former  experiment  in  which  injections  containing  zymotic 
organisms  had  been  made  into  a  vein.  As  a  result  the  dog  had  suffered 
severely,  but  had  apparently  recovered.  It  may  be  fairly  inferred  that  some 
of  these  organisms  had  remained  in  the  body  and  thus  caused  an  error  in  the 
.subsequent  experiment. 

The  obser\'ations  of  Klebs  gave  rise  to  the  further  suggestion  that 
blood  which  has  been  infected  may,  even  after  the  lapse  of  a  considerable 
period,  under  proper  conditions,  such  as  the  reception  of  an  injury,  give  rise 
to  the  active  processes  described.  Experiments  made  by  C  h  a  u  v  e  a  u 
bearing  on  this  point  are  very  striking.  Male  goats  were  injected  ^rith  cul- 
tures of  microorganisms  and  the  testicles  afterward  subjected  to  the  subcu- 
taneous separation  of  the  spermatic  cord  in  such  a  manner  as  to  rob  them 
of  their  blood-supply.  Rapid  putrefaction  followed,  just  as  if  the  organs 
had  been  infected  from  without.  Animals  thus  treated,  but  not  injected  with 
pathogenic  organisms,  suffered  simply  from  atrophy.  In  another  experiment 
the  animal  was  subjected  to  the  same  operation  on  the  left  testicle,  prior 
to  inoculation,  and  on  the  right  after  inoculation ;  the  latter  alone  under- 
went sloughing  and  putrefaction. 

Occurrence  and  Spread  of  Microorganisms.— Death  and  decay  are  of 
daily  and  hourly  occurrence  wherever  animal  and  vegetable  life  exist.  In 
the  frozen  regions  of  the  north,  however,  decay  does  not  follow  dissolution, 
for,  of  the  three  factors  necessary-  to  reproduce  microbic  life,  heat,  moisture, 
and  organic  matter,  the  first  is  wanting,  and  therefore  the  process  of  putrefac- 


ETIOLOGY    OF    INFLAMMATION  17 

iion  is  inlubitecl.  Tho  undecayed  remains  of  Ion-  extinct  mammoths  in 
bihena  are  examples  ol  this.  So,  too,  in  certain  portions  of  the  tropics,  because 
of  the  extreme  ch-yness  of  the  air,  rapid  desiccation  takes  place  and  the  dead 
body,  deprived  ot  its  moisture,  simply  mummifies.  Here  the  second  factor 
moisture,  is  absent.  This  desiccating  process  is  sometimes  taken  advantage 
oi  m  preserving  meats,  as,  for  instance,  the  "jerked  beef"  of  the  plains 

Except  under  these  exceptional  circumstances,  however,  dead  animals  or 
vegetable  tissues  decay  and  become  the  birthplace  of  new  germs  of  putrefac- 
tion to  be  taken  up  by  the  atmosphere  as  dust  when  the  process  of  disintegra- 
tion has  advanced  far  enough.  This  cannot  happen  while  the  decaying  mass 
IS  ma  moist  condition,  but  only  after  its  evaporation  and  the  conversion^of  the 
dried  and  broken-doNMi  tissues  into  dust,  ^^•hich,  disseminated  through  the  air 
iurmshes  constant  accessions  to  germ  life.  ' 

At  great  elevations,  therefore,  beyond  the  level  at  which  vegetative  life 
can  grow,  and  beyond  the  confines  of  crowded  communities,  it  will  be  found 
that  comparatively  few  microorganisms  are  present  in  the  atmosphere      The 
classic-  experiments  of  T  3'  n  d  a  1 1 ,  carried  on  in  the  Alps,  show  this  to  be  true 
On  the  contrary-,  it  is  found  that  in  awampy  regions  where  vegetation  is  con- 
stanth-  undergoing  putrefactive  changes,  and  in  large  cities  and  thicldv  populated 
portions  of  the  country  where  more  or  less  deca^-ing  animal  matter  exists   the 
conditions  are  favorable  to  the  development  and  dissemination  of  o-erm'life^ 
These  germs  may  be  carried  out  to  sea  by  the  wind  or  transported  on  ships" 
and  become  foci  of  infection  in  distant  regions.     In  general,  howe^-er   it  mav 
be  s^aid  that  on  the  high  seas  the  air  is  practicallv  sterile,  being  free  from  dust 
In  pre-aseptic  times   surgical  practice  suffered  greatly  from  a  want  of 
knowledge  concerning  the  dissemination  of  wound  infections.     In  improperly 
built,  poorly  ventilated,  and  unclean  hospitals,  where  many  patients  with  sup- 
purating wounds  were   crowded  together,   the  putrefying  wound  secretions 
turmshed  to  the  atmosphere  an   unlimited  supply  of   germs.      Deposited  in 
connection  with  dust  on  instruments,  dressings,  and  the  persons  of  attendants 
these   organisms  were   conveyed    to   fresh  wounds,  which,  in   turn,  became 
infected,  and  furnished  new  sources  of  infection  and  reinfection:    this  consti- 
tuted a  vicious  circle  of  events. 

SURGICAL  BACTERIOLOGY 

_  In  the  preceding  pages  reference  has  been  made  to  bacteria,  or  oro-anisms 
microscopic  m  character  (microorganisms),  and  the  relation  which  these  bear 
to  the_  processes  of  putrefaction,  and,  through  their  irritating  influences  to 
the  etiology  of  inflammation.  Since  .this  subject  constitutes  the  essential 
groundwork  of  modern  surgical  practice,  it  demands  a  fuller  discussion  in 
this  connection. 

_  It  has  been  happily  stated  that  every  operation  in  surgery  is  an  experiment 
m  bacteriology  (Welch).  It  is,  therefore,  essential  that  the  surgeon 
should  ha^'e  at  least  an  elementary  knowledge  of  the  organisms  which  com- 
monly mfect  wounds,  in  order  to  exclude  them  intelligently.  Familiarity  ^^dth 
laboratory  methods  will  emphasize  the  precautions  to  be  taken  during  an 
operation  and  wfll  contribute  to  the  employment  of  intelligent  means  for  the 
purpose  of  securing  asepsis  or  antisepsis.     A  single  act  of  carelessness  or  over- 


18  INFLAMiMATlON 

sijiht  in  the  series  of  acts  that  make  up  an  operation  is  sufficient  to  vitiate  all 
the  precautions  that  have  been  taken  to  keep  the  wound  aseptic,  and  it  is  cer- 
tain that  unless  the  surgeon  understands  the  rationale  of  laboratory  procedure 
he  v-ill  often  defeat  his  own  best  efforts  by  mistakes  which  he  would  otherwise 
avoid.  Unless  the  methods  of  the  surgeon,  together  with  all  the  paraphernalia 
of  operation,  are  exact  and  precise,  and  competent  to  attain  the  ends  sought, 
namely,  perfect  sterilization  of  the  wound  and  its  surroundings,  the  antiseptic 
and  aseptic  procedure  will  prove  a  snare  and  a  delusion,  for  it  will  induce  a  false 
sense  of  security  in  the  operation  which  may  prove  dangerous  and  even  fatal 
to  the  patient. 

Bacteria. — Bacteria  are  unicellular  vegetable  organisms,  multiplying 
by  fission.  They  are  the  active  agents  in  that  process  of  degeneration  in 
organic  substances  which  we  call  putrefaction.  They  may  increase  and  produce 
their  characteristic  phenomena  of  decay  onh^  in  dead  tissues,  whether  plant 
or  animal,  in  which  case  the}^  are  called  saprophytes;  or  they  may  require 
living  tissue  for  their  development,  when  they  are  called  parasites.  Finally, 
they  may  flourish  under  both  conditions,  when  they  are  termed  facultative 
parasites.     As  strict  parasites,  they  may  or  may  not  be  disease-producers. 

With  regard  to  their  shape,  bacteria  are  divided  into  two  classes:  (1)  bacilli, 
rod-shaped  organisms,  longer  than  broad;  (2)  cocci,  the  spheric  forms.  The 
bacilli,  in  turn,  when  curved  are  called  comma  bacilli.  AVhen  comma  bacilli, 
increasing  as  they  do  by  fission,  are  grouped  end  to  end,  forming  a  spiral,  such 
a  group  is  called  a  spirillum. 

The  cocci  are  subdivided,  also,  according  to  their  grouping,  the  different 
and  characteristic  forms  of  the  various  species  depending  on  their  methods 
of  subdivision  when  undergoing  fission. 

When  subdivision  takes  place  in  one  direction  only,  but  that  indifferent, 
we  then  have  a  number  of  cocci,  either  solitary  or  occurring  in  irregular  groups, 
and  to  these  the  term  staphylococci  is  applied.  AVhen  fission  takes  place  in 
one  direction  only,  but  alwa3's  in  the  same  direction,  the  cocci  are  then  asso- 
ciated in  chains  and  are  described  as  streptococci. 

If  the  cocci  occur  mostly  in  pairs,  they  are  termed  diplococci.  A^-lien 
fission  takes  place  in  two  directions,  then  the  cocci  occur  in  groups  of  four,  and 
are  called  tetrads.  When  division  occurs  in  three  directions,  the  so-called 
packet  shapes  are  formed,  containing  eight  elements.  These  cocci  are  called 
sarcinae.  Other  subdivisions  and  varieties  of  bacteria  occur  and  have  been 
described  and  classified,  but  they  have  not  as  yet  been  shown  to  be  important 
as  disease-producers. 

With  regard  to  the  bacilli,  it  is  to  be  noted  that  many  varieties  in  the  shape 
of  rods  occur.  Some  are  scarcely  longer  than  they  are  broad,  as,  for  instance, 
Bacillus  prodigiosus,  which  for  this  reason  was  for  some  time  described  as  a 
coccus.  Some  rods  have  their  ends  well  rounded,  while  others  seem  to  be  cut 
off  sc^uare. 

The  size  and  length  of  the  rods  may  vary  somewhat,  e^-en  in  the  same 
species,  so  that  quite  long  threads  may  occur  together  with  shorter  rods.  So 
also  there  may  be  a  distortion  of  form  in  old  and  worn-out  cultures,  swellings 
and  constrictions  quite  different  in  form  from  the  original  bacillus.  Such  forms 
are  known  as  involution  forms. 

Bacteria  are  further  classified  with  regard  to  certain  peculiarities  in  their 
growth,  as  liquefying  and  nonliquefying  organisms,  aerobic  and  anaerobic. 


KTIOLOGY    OF    INFLAMMATION  19 

Tho  li(i\icfyino;  oro-anisnis  liave  the  property  of  liqucfyino;  c;clatin.  This  they 
do  by  secretini!;  a  pei)tonizing  ferment. 

Anaerobic  bacteria  are  those  that  grow  only  \\'hen  oxygen  is  excliulcd  from 
tlie  nutrient  niecUum.  Aerobic  bacteria  grow  only  in  the  presence  of  oxj'gen, 
while  facultative  organisms  grow  either  with  or  without  oxygen.  Some  ana- 
erobes will  tolerate  this  gas  in  minute  quantities,  while  others  reqviire  its  abso- 
lute exclusion  in  order  to  grow.     Such  are  called  strict  anaerobes. 

All  bacteria  multiply  by  fission.  The  cocci  ne^'er  increase  in  an}'  other 
wa}^  as  far  as  A\"e  know  at  present.  An  important  modification  of  the  process 
of  reproduction,  known  as  sporulation,  occurs  in  many  of  the  bacilli.  When 
this  takes  place,  the  individual  rods  develop  in  their  substance  a  small  and 
highly  refractive  oval  granule,  Avhich,  increasing  in  size,  finally  escapes  from  the 
parent  cell.  This  is  the  spore,  which  in  turn,  under  favorable  circumstances, 
again  changes  its  form  and  passes  into  a  shape  exactly  similar  to  that  of  the 
parent  cell.  The  spore  ma}'  be  considered  as  the  fruit  of  the  original  plant, 
and  develops  only  imder  circvmistances  favorable  to  the  growth  of  the 
parent  cells.  It  is  not,  as  was  formerly  supposed,  a  result  of  unfavorable 
environment.  Spores  differ  from  the  bacilli  in  one  ^'•ery  important  particular. 
They  possess  an  extraordinary  power  of  vital  resistance  far  in  excess  of  their 
originating  rod  forms.  Many  spores  resist  prolonged  boiling,  desiccation,  and 
the  action  of  chemic  agents  quite  sufficient  to  insure  the  destruction  of  the 
plants  themselves.  It  will  be  seen  at  once  how  important  to  the  surgeon  is  a 
kno^\•ledge  of  this  peculiarity  of  the  spore.-  All  bacilli  are  not  known  to  be 
spore-bearers,  nor  are  any  of  the  cocci.  In  the  nonspore-bearing  species  cer- 
tain individual  members  of  a  group  appear  under  the  microscope  to  be  slightly 
larger  and  more  refractive  than  the  others.  There  is  reason  to  believe  that 
they  are  more  refractory  also.  These  are  supposed  to  take  the  place  of  the 
spores,  and  are  called  arthrospores.  Sporulation  in  the  spheric  form,  if  it 
ever  takes  place,  is  thus  accomplished. 

Ptomains. — In  the  life  processes  of  animals  we  have,  as  a  result  of  tissue 
metamorphosis,  the  formation  of  certain  products  such  as  carbon  dioxid,  urea, 
etc.  So  it  is  with  the  higher  order  of  plants.  They  give  out  oxygen  and  absorb 
carbon  dioxid  as  a  result  of  their  development  and  growth.  Not  dissimilar 
are  the  bacteria  in  that  they,  too,  in  the  course  of  their  life  processes  originate 
certain  new  substances  as  the  result  of  the  tissue  changes  which  take  place  dur- 
ing the  process  of  decomposition.  These  substances,  as  has  been  before  stated, 
are  called  ptomains. 

There  are  both  poisonous  and  nonpoisonous  ptomains.  In  the  pathogenic 
species  of  bacteria  in  many  cases  the  specific  ptomain  which  they  originate  is 
the  active  agent  in  the  production  of  disease.  This  is  notably  true  of  tetanus, 
a  bacterial  disease  in  which  the  nervous  phenomena  are  entirely  due  to  the 
ptomain  formed  by  the  bacillus  of  tetanus.  During  the  progress  of  wound 
diseases  the  high  temperatures  and  the  vascular  paralys'es  which  occur  are 
caused  by  the  action  of  these  poisonous  substances  in  the  circulation.  Sup- 
puration itself  can  be  produced  by  the  ptomains  alone  of  certain  of  the  pus 
organisms.  The  blush  of  erysipelas  is  probably  due  to  a  vascular  paralysis 
caused  by  the  local  action  of  a  poisonous,  alkaloidal  substance  formed  by 
the  Streptococcus  pyogenes,  and  to  the  same  cause  are  due  the  high  tem- 
perature and  other  phenomena  of  fever. 


20  INFLAMMATION 

Culture  Methods. — Not  until  it  was  practicable  to  cultivate  bacteria  on 
artificial  solid  media  was  it  possible  to  isolate  and  classify'  the  different  varieties 
for  obser^-ation  and  experiment.  The  world  is  indebted  to  Robert 
Koch  for  the  media  which  are  now  used  in  all  lal)oratories  for  the 
cultivation  of  these  organisms.  The  fluid  medium  which  is  most  generallv 
used  is  Koch's  bouillon.  The  solid  media  are  nutrient  gelatin,  nutrient 
agar,  and  coagulated  blood-serum. 

The  bouillon  is  made  as  follows:  One  pound  of  lean  beef  is  fineh*  chopped 
and  added  to  one  liter  of  water,  then  boiled  for  half  an  hour  in  a  glass  flask. 
The  infusion  is  then  filtered,  neutralized  b}'  adding  drop  by  drop  a  saturated 
solution  of  sodium  carbonate,  and  again  boiled  for  an  hour  to  clear  it.  A  0.5  per 
cent  solution  of  sodium  chlorid  is  usually  added.  The  bouillon  is  subseciuently 
poured  into  test-tubes  which  are  sterilized  after  the  following  method,  known 
as  fractional  sterilization :  The  tubes  are  first  plugged  with  common  non- 
absorbent  cotton  and  subjected  for  one  hour  to  a  temperature  of  150°  C.  in  a 
hot-air  sterilizer.  The  bouillon  is  then  poured  into  the  tubes,  which  are 
re-plugged  and  placed  in  a  cage  made  of  wire  cloth,  and  this  in  turn  is  put  in 
an  Arnold  steam  sterilizer  and  exposed  to  flowing  steam  half  an  hour 
each  day  for  three  successive  days.  The  object  of  this  method  of  sterilization 
is  to  permit  the  spores  which  have  resisted  the  first  steaming  to  develop  into 
cell  forms  during  the  intervals,  and  then  to  destroy  them  by  the  second  and 
third  sterilizations.  This  method  is  thoroughly  effective.  It  is  to  be  noted 
here  that  all  cell  forms  of  bacteria  perish  after  an  exposure  of  ten  or  fifteen 
minutes  to  streaming  steam,  and  all  pathogenic  bacteria,  with  the  exception 
of  the  anthrax  bacillus,  perish  after  exposure  to  a  temperature  of  80°  C.  (176° 
F.),  yet  there  are  spores  which  resist  prolonged  boiling,  and  it  is  to  permit 
such  spores  to  germinate  into  the  less  refractory  vegetative  forms  that  the 
method  of  fractional  sterilization  has  been  adopted.  One  exposure  of  an  hour 
to  wet  steam  under  pressure  (35  to  40  pounds  per  scjuare  inch)  t\111  destroy 
all  spores,  but  as  this  requires  special  apparatus'' the  method  first  described 
is  that  usually  adopted. 

The  nutrient  gelatin  is  made  as  follows:  An  infusion  of  meat  is  made  by 
adding  to  one  liter  of  cold  water  a  pound  of  well-chopped  beef.  This  is  placed 
on  ice  for  twentj-four  hours  and  the  expressed  and  filtered  infusion  then 
cooked,  filtered,  and  neutralized  by  the  addition  of  a  solution  of  sodium  car- 
bonate, drop  by  drop.  To  one  liter  of  this  "flesh  water"  is  added  10  grams 
(154  grains)  of  peptone  and  0.5  per  cent  of  sodium  chlorid.  Ten  per  cent 
of  gelatin  is  then  added  to  this  mixture,  which  is  boiled  after  the  gelatin  has 
been  allowed  to  soak  for  a  time.  In  order  that  the  gelatin  may  be  perfect^ 
transparent  it  is  necessary'  to  clear  it  of  insoluble  precipitates,  which,  if  not 
removed,  would  render  it  cloudy.  This  is  done  by  adding  the  albumen  of  one 
egg  to  100  grams  (about  3  ounces)  of  cold  water.  This  is  gradually  poured 
into  the  gelatin  mixture,  which  is  stirred  constantly  with  a  glass  rod.  The  whole 
is  then  boiled  for  ten  minutes,  when  the  coagulum  of  the  egg-albumen  comes 
to  the  bottom  of  the  vessel,  together  A^dth  the  insoluble  residue  which  it  is 
sired  to  separate  from  the  nutrient  medium.  The  gelatin  thus  prepared  after 
filtration  is  poured  into  test-tubes  to  about  one-third  of  their  capacity.  This 
must  be  done  carefully  "\nthout  wetting  the  upper  portion  of  the  tube,  other- 
wise the  plug  of  cotton  A^ill  stick  to  the  tube  as  the  gelatin  sets,  and  it  ^^^.ll  be 


ETIOLOGY    OF   INFLAMMATION  21 

difficult  to  remove  it.  The  tubes  containing  the  gelatin  are  placed  in  a 
cage  made  of  wire  cloth,  put  in  an  Arnold  sterilizer,  and  subjected  to 
flowing  .steam  for  half  an  hour;  this  is  repeated  three  times  at  intervals  of 
twenty-four  hours,  in  the  same  manner  as  the  bouillon.  Too  prolonged  boiling, 
it  is  to  be  noted,  will  depri\-e  the  gelatin  of  its  property  of  solidifying  when 
cooled. 

The  agar  jelly  is  also  made  in  a  similar  manner,  except  that  a  vegetable 
gelatin  called  agar-agar  is  substituted  for  the  ordinary  gelatin.  This  is  the 
product  of  a  species  of  seaweed  in  Japan  and  has  a  melting-point  much  higher 
than  that  of  gelatin.  It  is  to  be  added  to  the  flesh  peptone  solution  in  the  pro- 
portion of  1  to  2  per  cent. 

This  medium  is  more  difficult  to  make  than  the  ordinary  nutrient  gelatin,  as  it 
filters  less  readily  and  is  consequently  more  troublesome  to  clarify.  For  filter- 
ing both  gelatin  and  agar  preparations  it  is  desirable  to  use  a  hot-water  filter. 
This  is  simply  a  double-walled  copper  receptacle  shaped  like  a  funnel  and  filled 
with  water  which  is  kept  heated  by  a  number  of  gas  jets  issuing  from  a  circular 
hollow  tube  perforated  for  the  jets  and  fastened  in  the  ordinary  way  to  a  retort 
stand.  The  glass  filter  is  slipped  inside  the  hollow  copper  funnel,  and  in  this 
manner  the  gelatin  or  agar  is  kept  hot  while  filtration  is  going  on.  In  the 
absence  of  such  an  apparatus  the  ordinary  glass  funnel  may  first  be  heated  by 
boiling  water,  and  after  the  agar  or  gelatin  is  poured  therein  its  walls  may 
be  kept  hot  with  cloths  wrung  out  of  boiling  water  and  continually  renewed. 

A  modification  of  the  ordinary  nutrient  agar  may  be  prepared  by  the  addi- 
tion of  5  per  cent  of  glycerin.  This  is  the  so-called  glycerin  agar,  and  is  a 
useful  medium  for  the  tubercle  bacillus,  which  will  not  grow  on  the  ordinary 
media.  After  the  addition  of  the  glycerin,  which  is  often  acid,  the  agar  must 
be  carefully  neutralized  as  before.  It  is  important  that  all  the  media  should 
be  neutral,  as  some  organisms  resent  even  a  trace  of  acid. 

Human  blood-serum  is  often  used  for  the  cultivation  of  organisms  which 
refuse  to  grow  on  other  media.  It  is  usually  obtained  from  maternity  hospitals 
and  is  sterilized  in  what  is  kno^Mi  as  a  blood-serum  sterilizer.  It  is  a  useful 
medium  for  the  diplococcus  of  gonorrhea,  which  will  not  grow  on  any  other 
medium. 

The  common  potato  is  sometimes  used  as  a  culture-medium.  To  prepare 
it  for  use,  the  tubers  must  first  be  well  scrubbed  with  a  brush  in  a  solution  of 
bichlorid  of  mercury,  1 :  500,  and  then  well  rinsed  in  sterilized  water.  Potato 
cylinders  may  then  be  cut  with  an  apple-corer  and  sliced  obliquety  to  their 
axis  in  order  to  secure  a  broad  flat  surface  for  inoculation.  This  is  the  method 
of  Bolton.  These  pieces  are  then  placed  in  test-tubes,  plugged  in  the 
ordinar}'  manner,  and  sterilized  as  usiial. 

All  these  different  media  have  their  own  peculiarities  and  indi^'idual  uses 
in  laborator}^  practice.  For  hospital  use,  the  chief  advantage  of  the  bouillon 
is  the  certainty  with  which  the  sterility  of  sutures  and  ligatures  may  be  tested. 
Dropped  into  a  test-tube  of  bouillon,  every  portion  of  the  material  to  be  tested 
comes  in  contact  with  the  bouillon,  Avhich  thus  offers  a  more  rigid  test  than 
solid  media. 

More  than  one  organism  ma}'  be  lodged  on  a  suture  or  ligature,  and  when 
these  grow  together  in  a  fluid  medium  there  is  no  way  of  isolating  and  sepa- 
rating the  different  species  from  one  another.     Thus  no  conclusions  with  regard 


22  INFLAMMATION 

to  the  pathogenic  power  of  different  organisms  coukl  ]i()ssil)l\'  be  reached, 
unless  we  possessed  some  means  of  separating  them  and  testing  their  properties 
indi^'idually.  Before  the  introduction  of  sohd  media  this  was  a  most  (hfhcult 
and  uncertain  process.  In  1881  Koch  introduced  Avhat  is  known  as 
the  plate  method  of  isolation,  which  is  as  follows:  Three  test-tubes  of  nutrient 
gelatin  ai'e  used,  numbered  in  rotation,  one,  two,  and  three.  Heated  until 
the  gelatin  is  fluid,  but  at  a  temperature  below  40°  C.  (104°  F.),  number  one 
is  inoculated  with  a  minute  quantity  of  the  material  whose  organisms  it  is 
desired  to  isolate.  This  is  done  by  means  of  a  fine  platinum  wire  in  the  end 
of  a  glass  rod,  the  point  of  which  being  bent  on  itself  forms  a  fine  loop.  To 
sterilize  the  ^xiTe,  it  is  first  heated  to  redness  in  a  Bunsen  burner  and  then 
made  to  take  up  in  its  loop  a  minute  quantity  of  the  material  to  be  used  for 
inoculation.  The  wire  loop  is  then  plunged  into  the  first  tube,  the  gelatin  being 
Avell  agitated.  From  tube  number  one,  thus  inoculated,  a  sowing  is  in  the  same 
manner  implanted  in  tube  number  two,  and  in  like  manner  number  three  is 
inoculated  from  tube  number  two,  the  wire  being  heated  to  redness  before  each 
sowing  to  insure  its  sterility.  Now,  it  is  evident  that  this  is  a  process  of  dilu- 
tion, and  that  each  successive  tube  will  contain  organisms  rapidly  diminishing 
in  number.  Three  sterilized  glass  plates  are  then  prepared  and  leveled.  The 
contents  of  tube  number  one  are  poured  on  plate  number  one,  and  so  on,  so 
that  finally  we  have  three  plates  covered  with  a  thin  layer  of  solidified  gelatin. 

In  plate  number  one  so  numerous  are  the  organisms  which  have  been  dif- 
fused through  the  gelatin  that  the  colonies  which  start  from  each  individual 
coalesce,  so  that  they  cannot  be  isolated,  but  in  plate  number  two,  after  a  time, 
numerous  isolated  points  may  be  seen,  each  of  which  is  a  colony  growing  from 
a  single  spore  or  plant,  and  therefore  an  unmixed  growth.  In  plate  number 
three,  as  the  individuals  are  far  fewer,  the  colonies  are  more  widely  scattered, 
so  that  the  whole  plate  may  contain  fewer  than  a  dozen  colonies.  These  plates 
are  all,  of  course,  protected  from  the  atmosphere  after  sowing,  so  as  to  prevent 
the  introduction  of  organisms  from  the  air.  This  may  be  conveniently  done 
as  follows:  Two  circular  glass  dishes  with  straight  sides  about  an  inch  and  a 
half  high  are  used,  one  just  small  enough  to  fit  inside  the  larger  dish.  The 
plates,  suitably  elevated,  are  placed  in  the  larger  dish  and  covered  by  the 
inverted  smaller  dish.  Sufficient  water  is  then  poured  into  the  larger  dish 
to  make  a  water  seal,  and  the  plates  are  then  left  to  develop  their  growth.  Of 
course,  the  removal  of  the  covering  dish  exposes  the  plates  to  the  contamination 
of  organisms  floating  in  the  air,  and  this  method  has  been  modified  by 
Petri  ^^ith  a  view  to  minimizing  the  chances  of  contamination.  He  pours 
the  inoculated  gelatin  into  three  shallow  circular  dishes  with  straight  sides  and 
covers  each  dish  with  one  similar,  but  a  little  larger.  These  little  receptacles, 
about  six  inches  in  diameter,  are  known  as  Petri  dishes. 

Most  organisms  grow  m^ore  or  less  rapidly  at  a  temperature  of  22°  C.  (70  F.), 
or  that  of  an  ordinary  room.  They  all  grow  much  more  rapidly,  however, 
at  blood-heat,  and  some  refuse  to  grow  at  any  other  temperature.  It  there- 
fore became  necessary-  to  devise  an  incubator  which  could  be  maintained  stead- 
fastly at  the  desired  heat  by  means  of  a  thermostat.  Koch's  device 
is  simply  a  double-walled  box  or  oven  mounted  on  a  standard.  The  space 
between  the  walls  is  filled  with  water,  to  which  heat  is  communicated  by  a  small 
flame  under  the  bottom  of  the  oven.     Radiation  is  prevented  by  covering  with 


KTIOI.OGV    OF    IXFLA.MAIATIOX 


23 


fVlt  the  outside  of  the  oven.  kSuch  ovens  usually  have  iloul)le  doors,  sometimes 
triple,  the  inner  ones  being  of  glass  (Fig.  1). 

There  is  usually  a  water-gage  at  the  side  to  show  the  height  of  the  water 
between  the  double  walls,  and  an  orifice  in  the  top  through  which  a  ther- 
mometer may  be  passed. 

There  are  numerous  thermostats  in  use  at  present,  all  depending  on 
the  expansion  of  a  column  of  mercury  to  regulate  the  flow  of  gas  to  the 
l)uruoi-,  the  mercury,  as  it  rises,  reducing  the  size  of  the  aperture  admitting 
the  gas.  increasing  the  size  as  it  falls.  The  Dunham  therinostat  is 
represented  in  Fig.  2.  It  is  usual  to  interpose  a  pressure  regulator  between 
the    house    s\stem   and    the   thermostat  in  order   to  obviate  the    effects   of 


Fig.  1. — Laboratory  Incubator. 


changes  of  pressure  in  the  mains  (Fig.  3).  The  small  jet  at  the  burner 
is  protected  from  accidental  extinction  b^'-a  cone  of  mica. 

A  hot-air  o^'en  is  useful  in  a  laboratory  for  the  purpose  of  ciuicldy  sterilizing 
the  test-tubes  ^^ith  their  cotton  plugs  previous  to  filling  them  -^Aith  the  various 
media.  This  is  simply  a  box  of  Russian  iron  with  double  walls  and  suitable 
shelves.  Heat  is  furnished  by  a  nest  of  Bunsen  burners  underneath  the 
bottom.  A  temperature  of  150°  C.  for  one  hour  will  completely  sterilize 
both  tubes  and  plugs. 

Identification  of  Bacteria. — With  regard  to  the  naked-eye  appear- 
ances of  bacteria  as  they  grow  on  the  different  media,  these  organisms  differ 
^ndeh^  In  stick  cultures  some  grow  within  the  narrow  boundaries  of  the  stab, 
while  others  send  out  branching  growths  therefrom  in  great  exuberance. 


24 


IXFLAMMATJON 


Fig.  2. — Dunham's 
Thermostat. 


Color  is  moreover  an  important  jooint  of  distinction  between  different 
organisms,  and  has  given  rise  to  a  classification  in  which  these  organisms  are 
divided  into  chromogenic  and  nonchromogenic  species.  One  produces  a  bright 
red  growth,  others  a  deeper  shade;  some,  again,  are  orange, 
some  }'ellow,  and  the  organism  of  blue  pus  imparts  a 
peculiar  bluish-green  tint  to  the  agar.  Color,  howe^ver,  is 
not  a  test  of  pathogenic  power,  many  of  the  pathogenic 
organisms  being  nonchromogenic  and  a  dirty  \\hite. 

The  odor  of  certain  organisms  is  to  some  extent  charac- 
teristic and  furnishes  a  means  of  identification.  Thus, 
Bacillus  ureae  has  an  odor  like  that  of  decomposing  urine. 
The  malignant  edema  l^acillus  generates  a  putrid,  offensive 
gas. 

Some  organisms  licjuefy  gelatin  and  gi^'e  a  characteristic 
funnel  shape  to  the  area  of  lic[uefying  gelatin  stab  cidture, 
and  again  the  liquefying  organisms  differ  widely  in  the  rap- 
idity with  which  they  bring  about  hquefaction. 

Microscopic  Examination. — It  is  to  be  seen,  therefore, 
that  the  organisms  may  differ  in  man}--  particulars,  and  that 
it  is  necessary  to  take  all  these  into  consideration  before  we 
appeal  to  the  microscope  for  final  adjudication.  Indeed, 
were  we  to  trust  to  the  microscope  alone  for  our  means  of 
identification,  very  few,  if  any,  are  the  bacteria  which  we 
could  identify.  It  is  as  necessary  to  know  the  behavior  of 
organisms  on  cul- 
ture-media as  it  is  to  be  able  to  recog- 
nize their  forms  under  the  microscope. 
Indeed,  ^^■e  gain  more  information  as 
to  the  identity  of  a  particular  or- 
ganism by  observing  the  peculiarities 
of  its  growth  than  we  do  b}'  the 
microscope,  which  may  simply  con- 
firm our  previous  conclusion. 

Methods  of  Staining. — In  the 
minute  quantities  which  are  required 
for  the  purpose  of  microscopic  ex- 
amination all  these  organisms  are 
colorless,  chromogenic,  or  nonchro- 
mogenic. It  thus  becomes  a  matter 
of  difficulty  to  see  them  well  under 
the  microscope,  and  hence  for  pur- 
poses of  examination  they  are  stained. 
We  are  indebted  to  W  e  i  g  e  r  t  for 
this  very  great  addition  to  the  technic 
of  the  microscopic  examination  of 
these  organisms.  The  anilin  dyes  yig.  3.— Moiterseur's  pressure  Regulator. 
are  used  because  they  are  readily  ab- 
sorbed by  the  protoplasm  of  the  cells,  the  spores  remaining  unstained,  except 
by  the  aid  of  special  processes. 


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ETIOLOGY    OF    INFLAMMATION 


25 


Since  W  e  i  g  o  r  t  '  s  discovery  many  methods  of  staining  bacteria  have 
been  invented.  Only  three  formulas  will  be  ,2;i\'cn  here,  which  will  be  quite 
sufficient  for  ihe  purposes  of  the  "general  suro;eon.  For  a  j2;eneral  stain  that 
known  as  the  alkaline  methylene-blue  (Loffler)  is  probably  the  best. 
It  is  made  as  follows: 

To  30  c.c.  of  saturated  alcoholic  solution  of  mcthylono-blue  add  100  c.c. 
of  a  solution  of  caustic  potash. 
1 :  10,000.  This  stain  may  be  kept 
in  a  bottle  through  the  cork  of 
which  has  been  thrust  a  dropping 
tube  with  rubber  compressor.  It 
is  a  most  useful  stain.  In  per- 
manent preparations,  however,  it 
will  fade. 

In  examining  bacteria  in  pus, 
sputum,  etc..  the  dried  albumin 
also  takes  the  stain.  This  is 
often  confusing,  and  it  becomes 
desirable  to  remove  the  coloring 
in  some  way  and  yet  leave  the 
bacteria  stained.  Gram's 
method  does  this  satisfactorih-. 
Some  organisms,  that  of  gonor- 
rhea, for  instance,  do  not  retain 
their  color  in  Gram's  stain, 
so  that  this  method  may  be  used 
for  the  purpose  of  differentiation. 

The  Ziehl-Neelsen  method  removes  the  stain  not  onlv  from  extra- 
neous material,  but  from  all  organisms  except  Bacillus  tuberculosis,  so  that 
this  also  is  available  for  the  purpose  of  differential  diagnosis. 

In  the  method  of  Gram  there  are  two  solutions,  a  stain,  and  a  decolorizing 
agent: 

Gram's  Stain. 
Saturated  aqueous  solution  of  methyl-violet. 

Decolorizing  Solution. 
lodin    1  part;  potassium  iodid,  2  parts;  water,  300  parts.     The  preparation  is  first 
stained,  then  immersed  in  the  decolorizing  solution  for  a  minute  or  longer,  then  cleared. 

The  Ziehl-Neelsen  formula  for  staining  tubercle  bacilli  is  as  follows: 

Carbol-fuchsin. 

Fuchsin Ice 

Alcohol '.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'..10  c'c! 

When  dissolved,  add  100  c.c.  of  a  5  per  cent  solution  of  carbolic  acid. 

All  these  stains  require  to  be  freshly  made  every  now  and  then,  as  by  long 
standing  the}-  deposit  the  dye  in  the  walls  of  the  bottle  and  so  lose  in  efficiency. 

Method  of  Examination  by  the  Microscope.— A  minute  quantity  of  the 
organism  to  be  examined  is  taken  up  in  the  pre\-iously  flamed  loop  of  platinum 
wire  and  spread  very  thinly  over  a  cover-glass  (smear  preparation) .     If  neces- 


FiG.  4. — Hot-air  Sterilizer. 


26  IXFLAMMATIOX 

san^,the  smear  may  be  still  further  attenuated  by  the  addition  of  a  loopful  of 
sterilized  ^A•ater.  The  preparation  is  then  allowed  to  dry  spontaneously.  The 
cover-glass  is  then  seized  in  a  pair  of  forceps  and  passed  three  times  through  the 
flame  of  a  Bunsen  burner,  smeared  side  up.  If  the  alkaline  blue  solution  is  used 
a  drop  of  this  may  be  placed  on  a  glass  slide  and  the  cover-glass  then  placed, 
smeared  side  down,  on  the  drop  of  stain,  so  as  to  exclude  air-bubbles.  The  sur- 
plus stain  which  exudes  from  the  edges  of  the  cover-glass  is  then  to  be  blotted 
off  by  a  piece  of  filter-paper  placed  over  the  slide  and  coA'er-glass,  and  gentlv 
pressed  thereon.  Sufficient  stain  will  remain  to  keep  the  cover-glass  fixed  to 
the  slide.  A  drop  of  cedar  oil  is  then  placed  on  the  cover-glass  and  the  specimen 
is  ready  for  examination  with  the  homogeneous  immersion  lens.  In  the  Gram 
method,  after  the  specimen  has  been  stained  in  the  methyl-violet  solution  and 
subsequently  decolorized  as  before  directed,  the  decolorizing  fluid  is  to  be  washed 
off  with  sterilized  water  and  the  cover-glass  placed  on  the  slide  and  treated  as 
before.  There  must  always  be  some  fluid  between  the  slide  and  the  cover- 
glass,  but  not  sufficient  in  amount  to  float  it.  If  during  the  examination  the 
fluid  evaporates,  it  must  be  renewed  by  placing  a  drop  of  water  at  the  edge  of 
the  cover-glass,  which  will  be  drawn  underneath  by  capillary  attraction.  Speci- 
mens when  stained  may  be  permanently  mounted  in  Canada  balsam  after  they 
have  been  dried.  For  staining  tuberculous  sputum,  etc.,  the  application  of 
heat  is  necessary",  if  it  is  desirable  to  work  expeditiously.  This  may  be  done 
in  the  following  manner:  The  preparation  liaA'ing  been  made  and  dried  in  the 
usual  way,  the  cover-glass  is  flooded  with  the  carbol-fuchsin  solution  and  held 
over  the  flame  until  it  boils  vigorously  for  half  a  minute.  The  stain  is  then 
washed  off  and  the  slide  is  in  like  manner  flooded  with  the  decolorizing  solution. 
If  this  is  left  too  long  in  contact  with  the  preparation,  the  bacilli  themselves 
may  be  decolorized,  especially  if  faintly  stained.  A  little  practice  will  teach 
the  observer  the  proper  interval,  which  is  usually  not  over  one  minute,  and 
sometimes  less.  The  cover-glass  held  against  a  white  surface  should  show  but 
a  trace  of  color.  This  rapid  method  is  useful  for  diagnostic  purposes,  but  the 
evaporation  of  the  stain  when  boiled  leaves  unsightly  crusts  at  the  edge  of  the 
cover-glass,  so  that,  for  a  permanent  mount,  it  is  better  to  leave  the  specimen 
overnight  in  a  watch-glass  filled  vdih  a  cold  solution  of  the  carbol-fuchsin,  the 
decolorizing  method  being  identical  with  that  first  described. 

Common  Pus  Organisms. — It  now  becomes  necessary  to  describe  those 
organisms  that  the  surgeon  will  encounter  in  wounds  and  in  certain  diseases 
which  require  surgical  interference.  First  and  most  important  are  those  that 
induce  suppuration.  They  are  the  following:  Staphylococcus  pyogenes 
aureus,  Staphylococcus  pyogenes  citreus,  Staphylococcus  pyogenes  albus, 
Staphylococcus  epidermidis  albus  (Welch),  Streptococcus  pyogenes, 
and,  rarely,  Bacillus  pyogenes  soli  and  Bacillus  pyocyaneus.  Under  the 
microscope  Staphylococcus  pyogenes  aureus,  Staphylococcus  pyogenes  citreus, 
and  Staphylococcus  pyogenes  albus  do  not  differ  from  one  another,  nor  could 
they  be  thus  distinguished.  When  grown  on  nutrient  agar,  these  varieties  of 
staphylococci  differ  from  one  another  in  the  color  of  the  resulting  growth,  aureus 
being  a  golden  yellow,  citreus  a  citron  yellow,  and  albus  milk-white.  It  is 
to  be  observed,  however,  that  sometimes  the  color  is  slow  in  appearing  in  the 
citreus  and  aureus,  so  that  they  may  at  first  be  mistaken  for  albus.  With 
respect   to  the  behavior  in  gelatin,  all  three  organisms  produce  liquefaction 


ETIOLOGY    OF    INFLA.M.MA'I'IOX  27 

tlioutih  this  is  said  to  occur  soincwliat  nioi'c  slowly  in  the  citrous  than  in  the 
other  two.  Plates  of  these  or<i-anisnis  as  they  <i;row  on  slantinfz;  ao;ar  appear 
facing  page  28.  Staphylococctis  p}'ogenes  aureus  is  probably  the  most  common 
of  the  pus  organisms.  It  occurs  in  abscesses  and  furuncles,  in  empyema,  in 
the  metastatic  abscesses  of  so-called  pyemia,  in  osteomyelitis,  and  in  suppu- 
rative processes  in  general.  So  constantly  is  it  associated  with  osteomyelitis 
that  it  has  been  called  the  staphylococcus  of  osteomyelitis.  Numerous  experi- 
ments have  been  performed  with  pure  cultures  of  this  organism,  and  inocula- 
tions in  the  htunan  subject  have  been  uniformly  followed  by  suppuration. 
Pure  cultures  have  been  simply  ntbbed  into  the  uninjured  skin  and  have 
resulted  in  a  crop  of  abscesses  or  furuncles.  Osteomyelitis  has  likewise  been 
produced  in  animals  by  injecting  the  organism  into  the  circulation  and  then 
fracturing  a  bone. 

Less  common  and  perhaps  less  pathogenic  are  the  citreus  and  the  albus.  The 
citreus  has  been  recovered  from  postmortem  wounds  in  pure  culture  and  occurs 
in  suppurative  processes  in  general,  but  less  frequently  than  the  aureus.  The 
albus  has  likewise  been  found  to  occur  in  abscesses,  but  it  is  more  commonly 
found  associated  with  other  organisms  than  alone.  It  is,  however,  capable  of 
exciting  suppurative  processes  in  pure  culture,  but  it  is  not  so  virulent  as 
the  aureus.  With  regard  to  Staph3'lococcus  epidermidis  albus.  Professor 
Welch  has  shown  that  this  is  a  constant  inhabitant  of  the  epidermis,  occur- 
ring in  the  follicles  and  the  deeper  layers  of  the  skin.  It  is  not,  therefore, 
easily  reached  by  antiseptics.  Its  pathogenic  power,  fortunately,  is  feeble,  but 
it  is  the  most  common  cause  of  "stitch  abscess,"  and  is,  therefore,  of  special 
interest  to  the  surgeon. 

Some  observers  have  supposed  that  this  organism  is  identical  with  the  ordi- 
narv  white  staphylococcus,  or  is  merely  an  attenuated  form  of  the  latter,  Avhich 
supposition  seems  not  improbable. 

Streptococcus  pyogenes. — Streptococcus  pyogenes  is  an  organism  which 
is  of  paramount  importance  to  the  operating  surgeon.  It  is,  if  anything,  even 
commoner  than  the  golden  staphylococcus.  It  occurs  on  the  hair  and  on  the 
cutaneous  and  mucous  surfaces,  but  especially  on  the  latter,  particularly  in 
the  mouth.  It  is  now  generally  accepted  as  the  cause  of  erysipelas,  but  it 
is  found  in  suppurating  wounds  which  are  not  markedly  erv^sipelatous, 
though  in  such  cases  there  is  frequently  observed  a  faint  blush  about  the  edges 
of  the  wound.  In  erysipelatous  wounds  it  may  be  recovered  from  the  red  mar- 
gin of  the  advancing  inflammation  by  puncture  and  subsequent  inoculation. 
It  is  nonchromogenic  and  nonliquefying,  in  this  latter  respect  differing  from 
the  three  first  described  staphylococci.  It  may  be  recognized  under  the  micro- 
scope as  growing  in  chains  and  not  in  groups.  It  has  given  rise  to  erysipela- 
tous inflanunations  when  inoculated  in  the  human  subject,  as  Avell  as  when 
inoculated  in  animals.     It  is  also  the  cause  of  puerperal  fever. 

Bacillus  pyogenes  soli  was  discovered  by  B  o  1 1  o  n  in  1892  during 
his  experiments  with  tetanus  at  the  Hoagland  Laboratory.  It  is  found  in  the 
soil  and  in  pure  cultures,  and  occttrs  as  irregularly  shaped  short  rods,  some- 
times swollen  at  the  ends;  these  stain  irregularly.  It  is  a  facultative  anaerobe, 
does  not  liquefy  gelatin,  and  is  nonmotile.  It  does  not  grow  well  in  agar,  but 
best  in  gelatin  which  is  slightly  acid.  Data  are  wanting  in  regard  to  its  patho- 
genesis in  man.     In  a  case  admitted  to  St.  Marsh's  Hospital  it  was  recovered 


28  INFLAMMATION 

in  pure  culture  from  an  extensive  phlegmon  of  the  calf  occurring  after  an  abra- 
sion of  the  skin  about  the  Achilles  tendon,  into  which  much  earth  had  been 
ground. 

Bacillus  pyocyaneus  (Plate  I ,  Fig.  2)  is  a  slender  bacillus  witli  rounded 
ends,  occurring  in  pairs  and  also  in  chains  of  four  or  more  cells.  It  is  both 
liciuef}'ing  and  motile  and  possesses  the  curious  faculty  of  imparting  a  peculiar 
bluish-green  color  to  agar  or  gelatin.  This  coloration  is  diffused  through  the 
medium  and  is  not  confined  to  the  growth  itself.  It  is  a  transparent  and  some- 
what fluorescent  color.  From  this  the  bacillus  gets  its  name,  pyocyaneus, 
or  the  bacillus  of  green  pus,  to  which  it  imparts  the  greenish  color.  In  three 
cases  occurring  in  my  service  in  St.  Mars-'s  Hospital,  in  which  it  was  found  in 
pure  culture,  there  was  present  a  progressive  and  rapid  gangrene. 

The  diplococcus  of  gonorrhea  (the  gonococcus  of  X  e  i  s  s  e  r  )  (Plate  I, 
Fig.  4),  though  not  usually  associated  with  wounds,  is  nevertheless  a  pus-pro- 
ducer. It  is  probable  that  the  cases  of  suppurative  adenitis  and  acute  prostatitis 
which  sometimes  accompany  a  gonorrhea  are  due  to  infection  by  this  organism. 
The  virulent  and  destructive  ophthalmia  which  follows  its  introduction  into 
the  eye  is  too  well  known  to  need  comment. 

The  affection  described  as  gonorrheal  rheumatism  has  been  ascribed  to 
the  diplococcus  of  gonorrhea,  though  the  latter  cannot  always  be  identified. 
Some  writers  deny  that  it  is  the  cause,  and,  indeed,  with  regard  to  the  so-called 
metastatic  inflammations  of  gonorrhea,  the  adenitis  and  prostatitis,  they  assert 
that  these  sequels  are  due  to  an  infection  by  the  golden  staphylococcus  of 
suppuration.  The  following  case  occurred  in  1890  in  the  practice  of 
A.  T.  B  r  i  s  t  o  w  :  A  young  gentleman  consulted  him  with  an  angr\-  look- 
ing pimple  just  below  the  patella.  In  two  or  three  days  this  developed  into 
a  suppurative  bursitis.  Examination  of  the  pus  microscopically  showed 
numerous  diplococci  present  in  the  pus-cells,  but  no  other  organisms.  These 
were  identified  by  B  o  1 1  o  n  as  the  diplococci  of  gonorrhea.  The  patient  then 
admitted  the  existence  of  the  gonorrhea.  He  had  evidently  inoculated  a  mos- 
cjuito  bite  with  the  organism,  which  in  turn  had  infected  the  neighboring  bursa. 
Certainly  it  does  not  seem  unreasonable  to  suppose  a  pj-iori  that  an  organism 
which  is  capable  of  exciting  so  virulent  an  inflammation  as  gonorrheal  ophthal- 
mia should  also  be  competent  to  cause  the  complications,  suppurative  and 
nonsuppurative,  which  so  often  follow  gonorrhea.  It  has  never  been  shown 
that  these  complications  follow  suppurative  urethritis  caused  by  one  of  the 
other  pyogenic  organisms  (pseudo-gonorrhea).  In  the  case  mentioned,  this 
diplococcus  and  no  other  organism  was  recovered  from  the  pus,  the  patient's 
condition  being  unkno\m  to  his  surgeon. 

The  diplococcus  of  gonorrhea,  or,  as  it  is  most  commonly  called,  the  gonococ- 
cus, is  a  micrococcus  which  occurs  in  pairs,  sometimes  in  tetrads,  division  taking 
place  in  each  plane  alternately.  The  opposed  sides  of  the  cocci  are  slightly 
concave,  so  that  they  haA^e  been  described  as  biscuit-shaped.  The  gonococcus 
is  found  only  in  the  pus-cells  themselves,  and  as  there  are  several  other  organisms 
which  resemble  it  in  form,  some  being  found  even  in  th6  pus-cell,  the  following 
points  of  differential  diagnosis  must  be  borne  in  mind:  (1)  The  gonococcus 
does  not  take  the  Gram  stain,  i.  e.,  it  gives  up  the  color  in  the  decolorizing 
solution ;  (2)  it  refuses  to  grow  on  ordinary  media,  groAAing  with  some  difficulty 
on  blood-serum,  preferably  human  blood-serum.     Therefore,  if  an  organism 


PLATE   1 


M 


i. 


^ 


\^l^        ^ 


K 


ni.2,. 


^»4> 


Fi^.a. 


"'S^ 


'^Uif 


Jft 


Fi^.4. 


Fig.  1.  Bacillus  Prodigiosus,  Agar  Culture. 
Fig.  2.  Bacillus  Pyocyaxeus,  Agar  Culture. 
Fig.  3.  Tuberculous  Sputum. 
Fig.  -i.  (ioxococci.  Enclosed  in  Pus  Corpuscles. 


ETIOLOGY    OP    INFLAMMATION  29 

resembling;  the  o-onococcus  takes  the  G  r  a  m  stain,  or  if  it  can  be  grown  on 
the  ordinary  media,  it  is  not  the  specific  organism  of  gonorrhea,  exen  though 
it  resembles  the  gonococcus  in  other  particulars. 

The  gonococcus  stains  somewhat  slowly  with  the  L  5  f  f  1  e  r  stain  ; 
more  readily  with  the  methyl-violet  solution  of  the  Gram  stain. 

Specific  Pathogenic  Bacteria. — Lustgarten  and  others  have 
claimed  that  syphilis  is  a  bacterial  disease,  and  different  organisms  ha\'e  been 
described  in  this  connection,  but  at  present  the  matter  is  not  sufficiently  well 
settled  to  deserve  more  than  passing  notice  in  this  place.  So,  too,  with 
chancroid ;  as  yet  no  definite  organism  has  been  associated  with  either  the 
sore  itself  or  the  resulting  bubo.  It  seems  probable,  however,  that  in  all 
these  diseases  bacterial  infection  plays  an  important  part. 

Diphtheria  may  occur  in  wounds,  and,  as  the  surgeon  is  sometimes  called 
upon  to  perform  tracheotomy  in  the  course  of  the  disease,  a  brief  description 
of  the  organism  may  not  be  out  of  place.  The  organism  is  a  bacillus  known 
as  the  Klebs-LbflEier  bacillus,  K  1  e  b  s  having  discovered  it  in  diphtheritic 
membrane,  its  identification  with  the  disease  being  completed  by  L  o  f  f  1  e  r  . 
Its  morphology  is  somewhat  peculiar.  It  is  sometimes  c^uite  straight,  some- 
times curved,  and  in  a  single  cover-glass  preparation  both  forms  may  be  seen; 
some  are  swollen  at  the  ends,  some  in  the  middle.  Often  it  stains  irregularly. 
It  does  not  form  spores,  nor  are  the  rods  eA^er  seen  in  threads.  It  stains  well 
with  the  L  o  f  f  1  e  r  meth^dene-blue.  With  regard  to  its  behavior  in 
culture-media,  it  is  aerobic,  nonmotile,  and  nonliquefying. 

The  Bacillus  of  Tetanus. — One  of  the  most  important  of  wound  diseases 
with  which  the  surgeon  is  confronted  is  tetanus,  though  its  importance  is 
derived  rather  from  its  fatal  character  than  from  the  frecjuenc}"  with  which 
it  occurs.  Formerly  this  disease  was  attributed  to  wounds  of  nerve  structures, 
but  the  researches  of  N  i  c  o  1  a  i  e  r  ,  K  i  t  a  s  a  t  o  ,  and  others  have  sIioaati 
that  it  depends  on  a  peculiar  bacillus  called,  from  its  discoverer,  the  bacillus 
of  N  i  c  o  1  a  i  e  r  . 

This  organism  is  a  rather  slender  rod,  usualh'  bearing  a  single  spore  at  one 
end,  so  that  the  bacillus  and  spore  resemble  a  drumstick.  In  pure  cultures 
not  only  the  drumstick,  but  separate  spores  also  are  found. 

This  bacillus  is  a  very  strict  anaerobe  and  must  be  cultivated  in  an  atmos- 
phere from  which  oxygen  is  excluded.  For  the  surgeon  a  convenient  method 
of  accomplishing  this  is  as  follows :  Nutrient  agar  in  a  test-tube  is  melted  and 
allowed  to  cool  to  80°  C.  (176°  F.).  It  is  then  inoculated  in  the  usual  manner 
with  the  secretion  of  the  wound  and  kept  at  80°  C.  for  the  space  of  twenty 
minutes.  This  temperature  kills  the  other  organisms  which  may  be  present, 
but  does  not  affect  the  spore  of  tetanus,  because  of  its  high  power  of  resistance. 
The  agar  is  then  allowed  to  cool,  and  after  it  has  set,  the  remainder  of  the  tube 
to  within  a  sliort  distance  of  the  cotton  plug  is  filled  with  liquid  agar.  This 
thick  layer  of  superincumbent  agar  prevents  the  oxygen  from  gaining  access 
to  the  inoculated  la}'er  at  the  bottom  of  the  tube,  in  which  the  tetanus  bacilli 
then  develop  in  about  forty-eight  hours  if  placed  in  the  incubator.  The  colo- 
nies have  a  peculiar  shape  as  they  grow,  sending  out  long  fuzzy  prolongations 
from  the  parent  colony,  as  represented  in  Plate  II,  Fig.  5.  They  never  grow 
very  near  the  surface  of  the  agar.  When  cultivated  in  gelatin,  the  tetanus 
bacillus   slowly   liquefies   the    medium.     It  is  a   gas-producer  to   a   limited 


30  INFLAMMATION 

extent,  and  motile.  This  organism  is  not  found  in  tlie  blood  nor  in  tissues 
remote  from  the  wound.  It  must  be  recovered  from  the  wound  itself  or  from 
the  immediate  vicinit>'.  Cultures  exposed  to  diffused  daylight  soon  lose  their 
pathogenic  power.  This  may  account  for  the  fact  that  some  observers  have 
failed  to  produce  the  symptoms  of  tetanus  in  animals  by  cultures  not  kept 
in  the  dark.  The  nervous  symptoms  of  tetanus  owe  their  origin  to  two 
extremely  poisonous  alkaloids,  called  tetanin  and  tetanotoxin,  either  of  which 
when  injected  into  susceptible  animals  causes  the  s}'mptoms  characteristic  of 
the  disease.  Besides  these  alkaloids,  a  toxalbumin  has  been  isolated  which 
is  said  to  be  still  more  poisonous.  Some  observers  have  claimed  that  the 
poisonous  product  of  the  tetanus  bacillus  is  of  the  nature  of  a  ferment. 

The  Anthrax  Bacillus. — This  organism  is  of  special  interest  to  bacteriolo- 
gists because  it  was  the  first  organism  that  was  conclusively  shown  to  be  patho- 
genic. Koch  demonstrated  the  relation  between  the  anthrax  bacillus 
and  the  disease  of  cattle  called  splenic  fever  by  inoculating  animals  with  pure 
cultures  of  the  bacillus.  Never  before  had  any  organism  been  grown  on  arti- 
ficial media,  and  it  was  from  this  time  that  the  science  of  bacteriology  began 
to  have  a  firm  basis.  The  anthrax  bacillus  is  of  interest  to  the  surgeon  because 
it  produces  in  man  the  gangrenous  spreading  ulcer  called  malignant  pustule. 
It  is  a  rather  long  bacillus,  with  sf(uarely  cut  ends,  is  rarely  seen  isolated,  but 
grows  for  the  most  part  in  long  threads,  usually  twisted  together  in  convolu- 
tions. It  is  a  spore-producer  when  in  contact  with  oxygen,  is  nonmotile,  aer- 
obic, and  slowly  liquefies  gelatin.  In  a  long  stab  in  gelatin  or  agar,  the  organism 
grows  to  the  end  of  the  stab,  but  more  abundantly  as  it  approaches  the  surface, 
sending  out  fuzzy  prolongations  sideways  which  are  most  abundant  at  the  top 
of  the  stab  and  hardly  visible  at  the  bottom.  In  this  respect  it  is  the  opposite 
of  the  tetanus  bacillus,  in  which  the  reverse  is  true.  The  gelatin  first  com- 
mences to  liciuefy  at  the  top,  as  shox^m  in  Plate  II,  Fig.  5.  In  Plate  II,  Fig.  4, 
are  shown  the  rods,  some  undergoing  spore  formation.  This  does  not  occur, 
it  is  to  be  remarked,  in  the  living  body,  therefore  in  a  cover-glass  preparation 
of  a  suspected  malignant  pustule  only  the  rods  Avill  be  seen,  never  the  spores. 
They  resemble  verv  closely  the  rods  of  the  hay  bacillus,  which  is,  however, 
motile.  To  observe  this  distinction  it  is  necessary  that  the  preparation 
should  be  examined  unstained  and  unflamed.  The  organism  of  malignant 
edema  somewhat  resembles  the  anthrax  bacillus,  but  is  motile  and  a  strict 
anaerobe,  and  ma\'  thus  be  distinguished  by  cultivation.  It  is  not  likely  to 
be  met  with,  howe\'er,  and  has  not  been  described  among  the  organisms  of 
wounds  because  its  pathogenic  power  in  man  seems  doubtful.  All  these 
organisms  stain  readily  with  L  o  f  f  1  e  r  '  s   stain. 

Bacillus  tuberculosis  (Plate  I,  Fig.  3).— In  1882  this  organism  was  proved 
by  Koch  to  be  the  specific  cause  of  tuberculosis.  It  is  found  in  the  sputum 
of  tuberculous  patients,  in  tuberculous  glands,  in  caries  and  in  those  joint  affec- 
tions which  are  the  result  of  tuberculous  infection.  It  has  also  been  shown  to 
exist  in  great  numbers  in  the  diseased  tissues  in  cases  of  lupus.  This  organism 
is  a  strict  parasite  and  exists  in  the  form  of  very  fine  rods,  usually  curved,  with 
rounded  ends.  The  organism  stains  with  great  difficulty,  but  when  stained 
retains  the  color,  resisting  for  some  time  the  decolorizing  agency  of  alcohol 
and  nitric  acid.  The  directions  for  staining  have  already  been  given  in  a  pre- 
vious part  of  this  section.     When  thus  stained,  all  other  organisms  having 


PLATE  11 


^^■* 


■^ 


'Oi 


^!^^-abj9 


^f<«| 


t 


'<.-'< 


V 


1.  Streptococcus  Pyogenics. 

2.  Staphylococcus  Pyogenes  Aureus. 

3.  Bacillus  Anthracis. 


4.  Bacillus  Tetani. 

5.  Stroke  Culture  op  Tetanus. 

6.  Culture  of  Malignant  Edema. 


ETIOLOGY    OF    INFLAMMATION  31 

boon  (l(H'ok)rize(l  h\-  the  action  of  tlie  alcohol  and  nitric  acid,  the  tubercle  bacilli 
are  seen  as  \Try  small  and  slender  red  rods,  with  empt>'  or  unstained  spaces 
in  indi\'idual  rods.  These  unstained  spaces  have  been  called  spores  by  some 
writers,  but  spore-formation  has  not  as  yet  been  shown  to  exist  in  connection 
with  the  tubercle  bacillus.  The  rods  are  extremely  fine  and  slender,  so  that 
it  takes  some  little  practice  to  see  them.  They  do  not  grow  on  ordinary  gelatin 
or  agar,  but  grow  readily  on  glycerin  agar  in  the  incubator,  not,  however,  at 
the  room-temperature.  The  organism  can  be  best  obtained  in  pure  culture 
from  a  nodule  in  a  case  of  tuberculous  meningitis  or  peritonitis,  care  being  taken 
to  avoid  contaminating  the  cultures  with  surface  organisms.  If  the  peritoneum 
is  used,  the  abdominal  wall  having  first  been  opened  to  the  transversalis  fascia, 
the  opening  into  the  peritoneum  should  be  made  with  a  sterile  knife  and  with 
appropriate  precaution.  A  tubercle  is  then  removed  from  the  peritoneum, 
crushed  on  a  sterile  surface,  and  implanted  on  a  slanting  glycerin-agar  tube. 
If  contamination  has  not  occurred,  no  growth  will  be  apparent  until  the  lapse 
of  two  weeks,  when  fine  grayish-white  points  will  be  seen  growing  at  intervals 
from  the  inoculated  surface.  These  slowly  increase  until  the  surface  of  the 
agar  is  covered  A^ith  a  dry  yellowish- white  growth,  looking  very  much  like  bread- 
crumbs, scattered  over  the  agar.  As  it  is  necessary  to  keep  the  tubes  in  the 
incubator  for  so  long  a  period,  either  they  must  be  sealed  above  the  cotton  plug 
with  sealing-wax,  or  the  air  of  the  incubator  must  be  kept  moist  by  a  vessel 
of  water  within.  It  is  not  always  easy  to  discover  tubercle  bacilli  in  tubercu- 
lous joints.  As  many  as  twenty  sections  were  made  before  the  bacilli  were 
discovered  by  one  observer.  R  o  s  w  e  1 1  Park,  however,  in  a  series 
of  observations  lasting  over  two  years,  was  almost  always  able  to  find  them. 
If  not  readily  found  ^^ith  the  microscope,  the  internal  surface  of  the  thigh 
of  a  guinea-pig  or  the  anterior  chamber  of  the  eye  of  a  rabbit  may  be  inocu- 
lated with  a  bit  of  the  tuberculous  material  from  the  joint.  In  about  six 
weeks  the  animal  will  die  of  tuberculous  infection.  Unfortunate  examples 
of  autoinfection  have  followed  operations  for  the  relief  of  tuberculous  affec- 
tions. A.  T.  B  r  i  s  t  o  w  has  observed  two  cases  where  tubercular 
nodules  of  the  skin  followed  slight  punctures  in  the  course  of  operations  on 
tuberculous  patients.  In  a  case  where  puncture  of  a  joint  of  the  thumb 
resulted  in  tuberculous  synovitis,  subsequent  general  infection  followed  and 
death  occurred  in  a  year  and  a  half. 

A  bacillus  occurs  about  the  genitalia  which  has  been  named  the  smegma 
bacillus,  and  which  bears  a  remarkable  resemblance  to  the  tubercle  bacOlus. 
It  may  occur  in  urine  which  is  being  examined  for  the  tubercle  bacillus 
and  give  rise  to  an  erroneous  diagnosis.  The  inoculation  test  would,  of  course, 
settle  the  c^uestion  beyond  a  doubt. 

The  Lepra  Bacillus. — Leprosy  is  a  disease  which  is  but  seldom  seen  in  our 
northern  latiiude.  though  on  account  of  importation,  cases  are  more  common 
now  than  formerly.  The  organism  of  leprosy,  the  so-called  lepra  bacillus,  very 
closely  resembles  that  of  tuberculosis,  in  regard  to  size,  general  appearance,  and 
behavior  when  brought  in  contact  with  decolorizing  agents.  It  is,  however, 
somewhat  smaller  than  the  tubercle  bacillus,  with  more  pointed  ends.  It  stains 
more  easily  than  the  bacillus  of  tuberculosis,  but  gives  up  its  stain  \^ith  the 
same  difficulty.  For  purposes  of  staining  the  same  solutions  may  be  used 
as  with  tubercle.  This  organism  has  never  been  successfully  cultivated  on 
artificial  media.     Its  causal  relation  to  leprosy  has  been  definitely  ascertained. 


32  INFLAMMATION 

The  Bacillus  of  Glanders. — ({landers,  while  primarily  a  disease  peculiar 
to  the  equine  race,  nevertheless  is  not  infrpquentl.v  communicated  from  dis- 
eased animals  to  man.  It  is  the  result  of  the  infection  of  the  animal  by  the 
bacillus  of  glanders  (L  o  f  f  1  e  r  and  Schiitz,  1882).  This  organism, 
too,  bears  some  resemblance  to  the  tubercle  bacillus,  but  is  shorter  and  thick-er! 
It  stains  with  some  difficulty,  but  easily  parts  with  its  stain  in  decolorizing 
fluids.  It  stains  most  readily  in  a  hot  solution  of  Loffler's  alkaline 
blue,  and  grows  fairly  well  on  all  media,  best  perhaps  on  glycerin  agar.  It 
is  aerobic,  nonmotile,  and  does  not  liquefy.  Pure  cultures  of  this  organism 
may  be  obtained,  if  proper  precautions  are  taken,  from  the  interior  of  the 
so-called  farcy  buds  or  nodules. 

NON-BACTERIAL  SUPPURATION 

Foreign  bodies  buried  in  the  tissues,  as  well  as  mechanic  and  chemic  irri- 
tation, have  long  been  looked  upon  by  surgeons  as  causes  of  suppuration.  After 
Lister's  demonstration  of  the  germ  origin  of  wound  suppuration, 
however,  many  referred  suppurative  processes  to  the  direct  intervention  of 
bacteria.  Some,  nevertheless,  held  that,  while  microorganisms  were  the  accom- 
paniment of  suppuration,  they  were  not  necessarily  the  cause  of  it. 

Experiments  conducted  with  the  view  of  settling  the  question  were  con- 
tradictory and  misleading  until,  as  familiarity  with  proper  methods  of  technic 
increased,  common  sources  of  error  were  eliminated.  These  consisted  princi- 
pally in  attempts  to  cause  suppuration  by  the  introduction  into  the  tissues 
of  such  substances  as  croton  oil,  mercury,  and  turpentin.  The  different 
results  obtained  by  different  observers  were  in  part  due  to  the  fact  that  the 
injected  animals  used  in  the  experiments  did  not  always  belong  to  the 
same  species.  Some  animals  are  peculiarly  susceptible  to  suppurative  and 
analogous  processes,  while  others  possess  a  comparative  immunity  from  them. 
Turpentin,  for  instance,  will  produce  these  in  dogs  but  not  in  guinea-pigs.  By 
far  the  most  common  and  serious  sources  of  error,  however,  arose  from  faulty 
aseptic  technic. 

Experiments  serving  to  show  that  suppuration  could  be  caused  by  heat- 
sterilized  pus,  which  presumably  contained  only  the  chemic  products  of 
pus  organisms,  were  reported  in  1878  (Pasteur).  These  were  confirmed 
in  1885  (Petrour),  the  animals  used  being  rabbits  and  guinea-pigs. 
Bouillon  cultures  of  Staphylococcus  pyogenes  aureus,  after  being  both  heat- 
sterilized  and  filtered,  produced  suppuration  (Christmas).  The  same 
results  were  obtained  from  injections  of  croton  oil  in  the  cellular  tissues 
beneath  the  skins  of  rabbits  (Councilman).  Experiments  conducted 
along  the  same  line,  with  the  precaution,  however,  of  placing  the  croton  oil  in 
hermetically  sealed  sterilized  glass  tubes  introduced  beneath  the  skin  of  the 
animals  and  broken  at  different  intervals  of  time  after  the  wounds  had  healed, 
gave  different  results.  In  no  case  Avas  real  pus  produced,  but  only  a  mass  of 
puslike  consistency.  This  is  to  be  regarded  as  one  of  the  changes  that  take 
place  in  fibrinous  exudations  as  the  result  of  the  solvent  action  of  living  cells 
on  tissues  destroyed  by  the  action  of  the  chemic  irritant  (Cheyne). 
In  this  connection  attention  may  be  called  to  the  property  which  chemic  sub- 
stances possess  of  attracting  or  repelling  certain  kinds  of  organisms  (chemo- 


GENERAL    DIAGNOSIS   OF   INFLAMMATION  33 

taxis).  In  the  case  of  tlie  chemic  substances  placed  beneath  the  skin,  both 
these  and  the  resulting  dead  tissue  exert  a  similar  chemotactic  action  and 
attract  the  leukocytes. 

The  introduction  of  calomel  \\ill  almost  invariably  produce  a  puslike 
matci-ial  which,  ho^^■ever,  differs  in  several  particulars  from  true  pus:  the  cell 
nuclei  arc  single,  cystic,  and  stain  only  feebly  (Steinhaus).  Finally, 
the  i^roducts  of  decomposition  produced  by  bacteria,  as  well  as  the  ptomains 
of  putrefaction,  such  as  cadaverin,  may  produce  pseudo-suppuration. 

Aseptic  suppurative  processes,  or  suppuratiA-e  inflammation  without  the 
presence  of  bacteria,  to  which  reference  has  been  made,  and  with  which  the 
results  of  irritation  with  jequirity  seed  (B  a  u  m  g  a  r  t  e  n)  are  to  be 
classed,  require  further  investigation  and  study.  The  fact,  however,  that  they 
are  germ-free  is  of  interest  to  the  surgeon,  and  with  more  extended  knowledge 
of  laboratory  methods  he  will  be  able  to  distinguish  between  these  and  sup- 
puratiA-e  inflammatory  processes  which  depend  on  bacterial  infection  (see 
Surgical  Bacteriology) . 

GENERAL  DIAGNOSIS  OF  INFLAMMATION 
Objective  Symptoms.— The  classic  objective  symptoms,  namely,  redness, 
heat,  and  swelling,  are  usually  perceptible,  the  first  to  the  sense  of  vision 
(mspection),    the    second    to    touch   (palpation),    assisted  bv   thermometric 
mstruments,  and  the  third  to  vision  and  touch. 

Inspection.— When  the  inflammation  is  deep-seated  or  but  slightly  devel- 
oped superficially,  inspection  may  not  reveal  the  presence  of  redness. '^  Swell- 
ing may  also  escape  observation,  particularly  if  the  point  of  infiammation  is 
covered  by  thick  fascia.  The  redness  of  infiammation  is  to  be  differentiated 
from  that  produced  by  mechanic  obstruction.  The  swelling  may  likewise 
prove  a  source  of  error  in  cases  where  it  is  due  to  the  presence  of  a  tumor. 
Here,  however,  the  redness  is  of  a  bluish  tint,  and  in  cases  of  long  duration  the 
superficial  vessels  are  more  or  less  dilated.  The  redness  of  acute" inflammation 
IS  evenly  diffused,  of  rather  light  color,  and  without  any  appearance  of  rami- 
fymg  vessels.  Changes  in  color  may  be  observed.  Subcutaneous  rupture 
of  vessels  and  effusions  of  blood  into  the  tissues,  together  with  the  subsequent 
breaking  down  of  the  red  blood-corpuscles  of  the  effusion,  cause  a  staining 
of  the  tissues  by  the  blood-pigment.  This,  combining  with  the  inflammatorv 
redness,  produces  the  peculiar  tints  of  yelloAvish  blue,  bluish  green,  or  even 
deep  brown. 

In  addition  to  the  redness  and  swelling,  inspection  sometimes  reveals  the 
presence  of  pulsation,  of  blebs  or  bullae,  of  points  of  sphacelus,  and  of  foreign 
bodies,  facts  -which  are  of  diagnostic  value.  Inspection  of  corresponding 
healthy  portions  of  the  body  should  always  be  made,  when  possible,  for  pur- 
poses of  comparison.  In  this  manner  slight  departures  from  the  normal  which 
otherwise  might  have  escaped  notice  are  made  apparent. 

Palpation.— When  employed  in  the  diagnosis  of  inflammation,  palpation, 
as  a  rule,  has  for  its  primary  object  the  discovery  of  that  cardinal  symptom 
of  inflammation,  elevation  of  local  temperature.  Exclusive  of  the  so-called 
cold  abscesses,  the  symptom  is  rarely  so  slightly  pronounced  as  not  to  be  dis- 
tinguished by  the  hand  of  the  surgeon  applied  to  the  skin  at  the  point  of 


34  INFLAMMATION 

inflammation.  It  is  comparative!}'  a  rare  circumstance,  in  acute  and  subacute 
inflammator}^  foci,  that  the  local  elevation  of  temperature  is  not  sufficiently 
great  to  permit  of  a  diagnosis  on  the  strength  of  this  symptom  alone.  The 
dorsal  surface  of  the  fingers  of  the  examiner  should  be  employed  rather  than 
the  palmar,  the  latter,  in  doubtful  cases,  being  nonsensitive  to  slight  changes 
of  temperature.  Here  a  comparion  of  the  point  under  examination  with  the 
corresponding  healthy  portion  of  the  body  will  often  prove  of  value. 

Palpation  is  further  employed  to  determine  the  presence  or  absence  of  fluc- 
tuation. This  symptom  depends  on  the  presence  of  fluid  at  the  point  of 
inflammation,  either  serous  or  suppurative.  It  is  based  on  that  physi- 
cal property  of  all  fluids  by  reason  of  which  they  produce  wavelike  movements 
in  the  mass  when  disturbed,  and  thus  transmit  the  sense  of  pressure  from  one 
side  to  the  other.  In  the  case  of  large  accumulations,  as,  for  instance,  serous 
effusion  within  the  peritoneal  cavity,  the  wave  can  be  distinguished  by  sight 
as  weU  as  by  touch,  especially  if  the  abdominal  walls  are  thin.  Fluid  which 
occurs  within  inflammatory  foci,  however,  is,  as  a  rule,  so  covered  by  tense 
and  unyielding  tissues  that  these  wavelike  movements  cannot  be  produced. 
Under  such  circumstances  advantage  is  taken  of  another  physical  property  of 
fluid,  that  of  propagating  pressure  ec|ually  in  all  directions.  The  finger  being 
placed  on  each  side  of  the  swelling,  alternate  pressure  will  convey  the  sense 
of  transmitted  motion,  always  to  the  passive  finger,  no  matter  in  which  axis 
of  the  tumor  the  fingers  are  placed.  In  estimating  the  importance  of  this  symp- 
tom in  any  given  case  the  surgeon  should  not  fail  to  appreciate  the  character 
of  the  tissues  overlying  the  site  of  the  supposed  fluctuation.  This  is  of  special 
importance  where  large  muscular  masses,  such  as  the  quadriceps  extensor  of 
the  thigh,  intervene,  most  of  the  sensation  which  otherwise  would  be  conveyed 
to  the  touch  being  lost,  unless  both  fingers  are  firmly  pressed  deep  into  the 
tissues.  The  right  index-finger  may  be  i^laced  at  the  margin  of  the  suspected 
swelling  and  steady  pressure  made  in  such  a  manner  as  to  increase  the  tension 
within  the  cavity  containing  the  fluid.  Pressure  made  at  some  other  point 
of  the  swelling  with  the  left  index-finger  will  lift  the  other  finger  to  the 
same  extent  to  which  the  fluid  is  displaced.  Should  the  right  index-finger 
remain  stationary  or  fail  to  feel  the  pressure  when  it  is  but  slightly  made  by 
the  left,  then  the  pressure  is  not  propagated  by  fluid  and  the  examination  is 
negative. 

All  collections  of  fluid  within  the  body  cannot  be  demonstrated  by  means 
of  palpation.  This  is  true  of  accumulations  of  pus  within  cavities  bounded 
by  bony  walls.  Not  only  may  cavities  with  rigid  walls  be  situated  in  bone, 
but  those  having  originally  soft  and  yielding  walls  may  become  changed  by 
inflammator}'-  processes  or  long-continued  pressure,  so  that  the  finger  fails  to 
make  any  impression.  This  is  most  likely  to  occur  where  collections  of  inflam- 
matory fluid  become  encysted.  Subfascial  phlegmons  of  an  acute  character 
also  do  not,  as  a  rule,  give  rise  to  the  sense  of  fluctuation  on  palpation,  but 
rather  appear  to  be  a  solid  infiltration,  until  they  find  their  way  through  the 
fascia,  when  a  ver}^  distinct  sense  of  fluctuation  may  exist  at  the  opening,  which 
also  may  be  plainly  felt.  It  frequently  happens  that  fluctuation  is  felt  when 
no  fluid  is  present.  This  is  called  pseudo-fluctuation,  and  it  depends  on  the 
failure  to  recognize  the  distinction  between  true  fluctuation  and  elastic  resist- 
ance.    Faulty  palpation  is  responsible  for  this  error,  which  may  be  avoided 


GENERAL    DIAGNOSIS    OF    INFLAMMATION  35 

by  strict  adherence  to  the  jjropcr  metliod  of  conducting  the  examination. 
The  sense  of  fluctuation  conveyed  by  muscular  tissue  when  largely  developed 
is  such  as  to  deceive  at  times  the  most  careful  observer. 

So  difficult  is  it  to  distinguish  between  the  fluctuation  of  muscle  and  that 
found  in  collections  of  fluid  in  some  situations,  such  as  the  thigh  or  the  thenar 
eminences,  that  the  result  of  an  examination  for  fluctuation  in  these  regions 
may  be  almost  without  value.  Muscular  fluctuation,  however,  it  may  he 
observed,  always  takes  place  across  the  axis  of  the  muscle,  never  in  the  direction 
of  the  axis.  Thus,  if  one  index-finger  is  placed  on  the  outer  margin  of  the  quad- 
riceps extensor  and  the  other  on  the  inner  margin,  a  very  distinct  sense  of  fluc- 
tuation may  be  produced  which  is  caused  by  the  rolling  of  the  fibers 
of  the  muscle  on  their  axes.  If,  however,  one  finger  is  placed  on  the  center 
line  of  the  muscle  belly  and  the  other  above  or  below,  on  the  same  line,  so 
that  the  motion,  if  any,  will  follow  the  axis  of  the  muscle,  muscular  fluctuation 
never  takes  place,  as  the  fibers  are  unable  to  roll  against  each  other  as  in  the 
other  case. 

Finally,  certain  solid  tumors  may  simulate  fluctuation.  Of  these,  myxomas 
and  sarcomas  are  to  be  particularly  mentioned.  These  either  contain  in  their 
tissues  large  amounts  of  nutrient  fluid,  or  are  peculiarh'  rich  in  cellular  elements 
or  cystic  formations.  The  history  of  the  condition,  together  with  the  presence 
of  some  of  the  other  signs  of  inflammation,  will  assist  in  the  diagnosis. 

Palpation  is  further  employed  to  determine  how  far  the  swelling  extends 
and  whether  or  not  it  is  movable  on  the  deeper  parts  (muscle,  fascia,  bone) ;  in 
other  words,  its  relation  to  surrounding  parts.  This  point  is  specially  impor- 
tant in  establishing  the  differential  diagnosis  between  an  inflammatory  swelling 
and  the  formation  of  a  tumor.  If  the  swelling,  whether  inflammatory  or  neo- 
plastic, is  in  the  neighborhood  of  a  large  vessel,  the  pulsations  of  the  arterv 
will  be  conveyed  to  the  finger  with  more  or  less  distinctness  and  may  be  visible 
to  the  eye.  This  is  found  to  the  greatest  extent  in  aneurisms.  Tumors  with 
fluid  contents,  however,  in  the  vicinity  of  large  arteries  transmit  the  arterial 
impulse  very  distinctly,  provided  there  is  much  tension  in  the  cyst  or  sac. 
Tumors  of  a  soft  or  compressible  character  transmit  pulsation  less  readily. 
Certain  growths,  such,  for  instance,  as  some  of  the  sarcomas,  in  Avhich  large 
nutrient  vessels  have  developed  also  exhibit  pulsation,  even  at  a  considerable 
distance  from  large  trunks.  Pulsation  is  also  present  in  the  brain  when  its 
bony  incasement  is  removed,  and  may  occasionally  be  detected  in  the  medullary 
cavity  of  large  bones. 

Friction  sensations  or  sounds,  as  they  are  sometimes  called,  are  conveyed 
through  the  palpating  finger  of  the  surgeon.  These  may  follow  injuries  of 
different  kinds,  but  are  specially  noticed  in  cases  in  which  considerable  blood 
is  extravasated  and  coagulated  in  the  connective- tissue  spaces.  There  is  also  a 
peculiar  crepitating  feeling  conveyed  in  cases  in  which  serum  is  forced  through 
elastic  effused  material.  In  serofibrinous  exudations  in  synovial  cavities,  par- 
ticularly Avhere  the  walls  of  the  latter  are  covered  by  a  proliferation  of  tissue, 
these  sensations  of  friction  are  also  felt. 

The  sense  of  hearing  is  not  often  employed  by  the  surgeon  for  diagnostic 
purposes  in  inflammatory  conditions.  In  instances  in  which  there  is  a  ques- 
tion of  differential  diagnosis  of  inflammatory  conditions  and  aneurismal  tumors, 
the  stethoscope  is  employed.     The  conditions  which  produce  the  sensation  of 


36  IXFLAM.MATIOX 

friction  above  alluded  to  also  produce  audible  friction  sounds,  but  for  the 
detection  of  these,  even  when  aided  by  the  stethoscope  and  its  modifications, 
the  sense  of  hearing  is  rarely  useful. 

The  sense  of  smell  is  likewise  employed  for  diagnostic  purposes  in  cases  in 
which  the  odors  are  given  off  by  gases  having  their  origin  in  foci  of  putrefaction. 

Instrumental  aids  to  diagnosis  have  long  been  employed  by  surgeons.  First 
ainong  them  is  the  probe.  This  little  instrument  is  intended  to  serve  as  a 
prolongation  of  the  finger,  and  gives  information  to  the  surgeon  of  the  condi- 
tion of  structures  which  communicate  Avith  the  air  through  either  natural  or 
artificial  channels,  but  Avhich,  by  reason  either  of  the  narroAATiess  of  the  channel 
or  of  its  depth,  are  inaccessible  to  the  touch.  It  is  also  used  to  determine  the 
location  and  presence  of  foreign  bodies,  such  as  bullets,  etc.,  and  necrotic  bone. 
In  the  treatment  of  old  sinuses  it  is  likewise  useful  to  convey  certain  medica- 
ments within  its  tract,  such  as  stimulating  applications,  caustics,  etc.,  or  a 
tampon  of  medicated  gauze,  or  a  drainage-tube. 

Exploratory  puncture  is  of  special  importance  in  the  diagnosis  of  certain 
inflammatory  conditions,  and  of  their  products.  This  is  generally  accom- 
plished by  means  of  the  aspirator,  though  a  deeply  grooved  needle  called  an 
exploring  needle  may  often  be  used  instead.  By  the  use  of  this  means  the 
presence  of  liquids  may  be  ascertained,  together  with  their  character.  For 
diagnostic  purposes  the  common  hypodermic  syringe  may  be  used,  the  needle 
having  been  first  sterilized  by  being  passed  through  an  alcohol  lamp. 

It  sometimes  becomes  necessary  to  employ  mensuration  for  the  purpose 
of  establishing  and  recording  differences  in  the  circumferences  and  lengths  of 
parts. 

As  aids  to  inspection  varieties  of  instrimients  are  employed.  Of  these, 
the  laryngoscope,  the  rhinoscope,  the  ophthalmoscope,  and  the  endoscope  are 
examples.  An  important  aid  to  diagnosis  of  which  surgeons  of  the  present 
day  avail  themselves  much  more  frequently  than  did  those  of  former  times  is 
the  microscope.  Its  aid  is  constantly  invoked  to  determine  the  nature  of  the 
products  of  disease,  the  malignancy  or  benignancy  of  neoplasms,  and  to  assist  in 
identifying  the  various  bacteria  of  wound  diseases.  Finally,  the  thermometer 
and  the  sphygmograph  are  employed  in  estimating  the  extent  of  the  partici- 
pation of  the  entire  oi-ganism  in  the  inflammatoiy  process.  The  thermometer 
measures  the  variation  of  animal  heat,  the  sphygmograph  the  changes  in  vas- 
cular tension.     (For  Laboratory  Aids  to  Diagnosis  see  page  243.) 

Fever. — In  ever}'  acute  inflammation,  whether  exudative  or  suppurative, 
more  or  less  constitutional  disturbances  arise.  Of  these,  the  most  important 
to  the  surgeon  is  fever.  This  scarcely  ever  commences  earlier  than  twenty- 
four  hours  after  the  reception  of  the  injury,  is  coincident  with  the  beginning 
of  putrefactive  changes  in  the  blood  and  the.  secretions  in  and  about  the  wound, 
and  pursues  a  course  parallel  to  these  changes,  rising  or  falling  according  as 
these  processes  are  rapid  and  extensive  or  the  reverse.  If  the  latter  are  mod- 
erate in  degree  and  extent,  there  may  be  simply  a  morning  and  an  evening 
rise  of  temperature,  with  subsec^uent  remissions.  The  occurrence  of  a  sud- 
den chill  followed  by  a  considerable  rise  of  temperature  (103°  F.  or  more) 
always  indicates  a  profound  degree  of  intoxication  through  influences  more  pro- 
nounced than  those  which  produced  the  original  fever. 

Coincidentally  with  the  rise  of  temperature  there  occurs  an  increase  in  the 


GENERAL    DIAGNOSIS    OF    INFLAMMATION  37 

frequency  and  force  of  the  pulse,  as  well  as  an  acceleration  of  the  respira- 
tions. There  is  a  more  constant  relation  between  the  temperature  and  the 
pulse,  however,  than  between  either  of  these  and  the  respiration. 

The  usual  and  typic  symptoms  of  anorexia,  impaired  digestion,  etc.,  occur- 
ring in  other  forms  of  fever,  likewise  exist  in  surgical  fever.  The  aversion  to 
meat  is  particularly  noticeable.  Even  liquid  food  is  taken  but  sparingly,  as 
the  digestion  is  much  weakened,  if  not  interrupted  altogether.  The  urine  is 
of  a  dark  wine-color,  due  to  the  presence  of  urates  in  large  cjuantities,  and 
usually  the  daily  quantity  falls  below  the  normal.  While  the  total  quantity 
of  urine  may  be  decreased,  there  is  nevertheless  an  increase  in  the  amount  of 
pliosphates,  urates,  and  particularly  the  potassium  salts  and  urea,  which  indi- 
cates an  increased  metamorphosis  and  waste  of  tissue.  The  albuminates  and 
their  derivatives  eliminated  are  derived  from  the  tissues  themseh'es.  This  to  a 
certain  extent  explains  the  emaciation  of  fever  patients.  During  this  time  the 
subjective  symptoms  are  well  marked.  Thirst  is  excessive,  restlessness  is  very 
great,  and  there  may  be  delirium.  With  the  occurrence  of  profuse  suppuration 
from  the  wound,  these  symptoms  gradually  subside  if  the  outpoured  pus  con- 
tains but  few  of  the  products  of  putrefaction  (laudable  pus  of  the  ancients). 
On  the  third  or  fourth  day  the  discharge  of  pus  is  well  established,  granulations 
spring  up,  and  the  wound  is  said  to  "  clean  off."  At  the  end  of  about  a  week 
the  temperature  falls  to  normal,  the  tongue  clears,  moisture  replaces  the  un- 
natural dryness  of  the  skin,  and  convalescence  is  established. 

Subjective  Symptoms. — In  estabhshing  the  diagnosis  in  any  given  case 
too  much  reliance  should  not  be  placed  on  the  patient's  history  as  given 
by  himself.  In  fact,  the  more  the  surgeon  relies  on  the  objective  symptoms 
to  the  exclusion  of  the  subjective  ones,  the  less  frequently  will  he  be  in  error. 
This  arises  from  the  fact  that  patients  are  apt  to  exaggerate  the  importance 
of  some  symptoms  and  to  belittle  others,  if  not  to  conceal  them  altogether,  as  in 
affections  of  venereal  origin.  At  the  same  time  we  cannot  entirely  ignore  the 
patient's  statements,  unless  there  is  good  reason  to  believe  that  he  is  a  malin- 
gerer. If  the  case  in  hand  is  of  traumatic  origin,  an  account  of  the  manner  in 
which  the  injury  was  received  Avill  ahvays  be  in  order.  Long  voluntary  state- 
ments should  even  here  be  discouraged  as  far  as  possible,  and  this  portion  of 
the  examination  should  take  the  form  of  question  and  answer.  Under  other  cir- 
cumstances, where  the  case  is  of  a  more  chronic  character,  only  the  bare  state- 
ment from  the  patient  as  to  the  part  affected  should  be  received,  after  which 
the  examination  should  be  categorical  and  physical.  The  form  of  the  inc{uiry 
should  be  based  on  what  the  surgeon  sees  or  feels  when  the  affected  part 
is  presented  to  him.  In  general  the  age,  occupation,  and  condition  in  life, 
whether  married  or  single,  are  useful  points  A^Tith  which  to  commence.  Then 
follows  an  inquiry  as  to  the  time  at  which  the  patient  first  noticed  the  impair- 
ment of  health.  After  this  the  s}'mptom  or  group  of  symptoms  which  first 
attracted  the  patient's  attention  is  inquired  into.  Then  comes  the  question 
as  to  the  persistence  or  abatement  of  the  symptoms  and  the  occurrence  of  new 
ones.  The  patient  should  thus  be  carried  through  the  course  of  the  disease 
until  the  present  time  is  reached.  A  series  of  short  and  sharp  inquiries,  made 
somewhat  after  the  manner  of  an  examining  attorney  addressing  a  witness, 
without  waste  of  words  or  time,  and  directly  to  the  point,  may  throw  con- 
siderable  light   on   the    case.     Under   no    circumstances   should  the  patient 


38  INFLAMMATION 

be  permitted  to  go  into  long  and  tedious  details,  and  when  disposed  to  do  so 
he  must  be  brought  back  to  the  proper  point  in  the  examination  by  a  well- 
directed  question.  The  main  points  bearing  on  the  case  must  be  borne  in  mind, 
the  patient  being  permitted  to  volunteer  but  very  little,  and  the  surgeon  ask- 
ing as  few  questions  as  possible.  The  tact  and  knowledge  necessary  to  carry  on 
an  examination  of  this  kind  can  be  obtained  only  at  the  patient's  bedside  or 
in  the  clinic.  Fixed  niles,  though  they  are  of  great  service,  cannot  be  made 
for  application  to  all  cases.  The  beginner  will  be  compelled  rapidly  to  nm 
over  in  his  mind  what  the  condition  before  him  may  he,  and,  having  grouped 
together  all  points,  he  will  proceed  to  determine  what  it  is.  Knowledge  of  all 
the  branches  of  medical  science  is  of  use  to  the  surgical  practitioner,  and  the 
information  gained  in  the  autopsy  room  is  of  the  greatest  possible  value. 

In  taking  into  account  subjective  symptoms,  particularly  that  of  pain,  the 
surgeon  will  be  careful  not  to  give  undue  consideration  to  them.  If  careful 
examination  does  not  reveal  any  good  and  sufficient  reason  for  the  exis- 
tence or  the  persistence  of  pain,  the  case  should  be  carefully  watched  for  objec- 
tive corroborative  symptoms  or  for  simulation.  If  the  patient  is  a  plaintiff- 
at-law,  the  surgeon  will  find  it  necessary  to  be  more  than  ever  on  his  guard. 
The  same  remarks  apply  to  local  points  of  tenderness.  The  surgeon  should 
ahvays,  in  doubtful  cases,  after  a  patient  has  complained  of  a  point  of  tender- 
ness, endeavor  to  verify  or  to  disprove  its  existence  by  distracting  his  atten- 
tion from  the  point  complained  of,  and  then,  without  the  patient's  knowledge, 
applying  as  nearly  as  possible  the  same  amount  of  pressure  as  before. 

Loss  or  impairment  of  function  may  be  present  as  a  subjective  symp- 
tom, or  its  presence  may  be  objectively  demonstrated  by  special  means  adapted 
to  that  purpose,  e.  g.,  electricity,  in  loss  of  function  of  muscles.  The  loss  will 
manifest  itself  in  various  ways,  according  to  the  part  affected.  A  glandular 
structure  may  cease  to  furnish  its  normal  secretion.  An  impairment  of  the 
special  senses  may  also  be  properly  included  in  the  subjective  symptoms. 

Finally,  it  should  be  borne  in  mind  that  but  few  diseases  or  inflammatory 
conditions  have  a  mereh^  local  importance.  The  local  inflammation,  for 
instance,  may  give  rise  to  a  general  disturbance,  as  in  traumatic  fever,  and 
vice  versa,  as  in  general  tuberculosis. 


TERMINATION  AND  PROGNOSIS  OF  INFLAMMATION 

Inflammation  may  terminate  (1)  in  resolution;  (2)  by  healing  and  cicatri- 
zation; (3)  in  death.  Termination  by  resolution  takes  place  in  the  majority 
of  cases  of  serous  inflammation.  The  effused  fluids  undergo  but  slight  changes, 
unless  infection  occurs,  and  are  soon  taken  up  by  the  lymphatics,  the  normal 
condition  of  the  tissues  being  then  restored,  In  cases  in  which  healing  by  the 
formation  of  cicatricial  tissue  occurs,  the  course  is  that  followed  by  all  suppura- 
tive and  some  granulating  forms  of  inflammation.  In  discussing  the  second 
manner  of  termination  of  inflammation  it  was  formerly  the  custom  to  speak 
of  it  as  terminating  in  suppuration.  That  this  is  illogical  may  be  seen  at  a 
glance,  because  the  suppuration  does  not  terminate  the  process  at  all,  but  is 
simply  an  incident  in  its  course.  Both  suppurative  and  gangrenous  inflam- 
mation, after  greater  or  lesser  loss  of  tissue,  proceed  to  cicatrization  in  a  com- 
paratively short  time.     In  cases  of  granulating  inflammation,  however,  the 


TERMIXATIOX    AXD    PROGXOSIS    OF    IXFLAMMATIOX  39 

repair  proceeds  much  more  slowly,  and  a  tendency  to  recurrence  is  manifested. 
The  granulating-  tissue  is  dcstro}-ed  as  rapidly  as  formed  under  the  influence 
of  the  pathosi-ciiic  microoro-anisms.  When  healthy  jjranulations  form,  cica- 
trization ma}'  take  place,  the  bacteria  being  prevented  from  coming  in  contact 
with  sufficient  pabulum  on  which  to  subsist,  and  licnce  perishing.  When 
caseation  takes  place,  a  healing  reparati^'e  process  is  impossil^le.  It  some- 
times happens  that,  within  the  area  of  a  granulating  inflammation,  the  organ- 
isms of  suppuration  penetrate,  and  an  acute  or  a  subacute  suppurative 
process  intervenes.  The  formation  of  pus  leads  to  destruction  of  the  diseased 
granulating  tissue,  the  pus  finds  its  way  to  the  surface  or  is  evacuated,  and 
cicatrization  occurs.  The  originally  infecting  pathogenic  bacteria  seem  to  be 
destroyed  in  the  process. 

Whether  lymphatic  resorption  of  pus  ever  occurs,  or  granulating  inflamma- 
tion undergoes  repair  without  leaving  cicatricial  tissue  behind,  is  uncertain. 

Death  occurring  from  the  direct  effects  of  the  presence  of  inflammation 
is  of  comparatively  rare  occurrence.  AMien  this  does  occur,  it  is  usually  the 
result  of  the  sloughing  away  of  the  walls  of  a  large  vessel,  death  taking  place 
from  acute  anemia  (hemorrhage).  But  death  occurs  frequently  from  the 
more  remote  effects  of  inflammation,  or  from  its  indirect  results.  In  the  great 
majority  of  cases  in  which  a  fatal  result  follows,  it  is  through  the  medium  of 
an  infection  from  the  seat  of  inflammation,  which  occasions  a  disturbance  of 
the  entire  organism.  A  familiar  example  of  this  general  infection  is  found 
in  traumatic  fever.  Although  this  is  not  particularly  threatening  to  life,  yet 
it  may  become  so  in  cases  in  which  the  vital  resistance  is  lowered  by  large  loss 
of  blood,  pre-existing  disease,  or  old  age.  When  the  reception  of  a  wound 
gives  rise  to  a  fatal  result,  the  immediate  effects  of  the  trauma  being  excluded, 
death  is  due  to  the  supervention  of  one  or  the  other  of  the  wound  sequels,  or 
wound  diseases. 

Granulating  inflammation  may  prove  fatal  by  infecting  the  entire  body, 
as  in  miliary  tuberculosis.  Amyloid  degeneration  of  the  spleen,  liver,  kidneys, 
and  blood-vessels  of  the  intestinal  canal  may  produce  a  fatal  issue  in  a  case  of 
long-standing  granulating  inflammation  of  tuberculous  origin.  'V\Tiile  our 
best  efforts  are  directed  toward  saving  life,  the  restoration  of  the  function  of 
the  part  which  is  the  seat  of  inflammation  is  also  entitled  to  some  considera- 
tion. This  will  depend  to  a  certain  extent  on  the  part  affected.  W^hile  mus- 
cular and  glandular  structures  show,  as  far  as  their  functions  are  concerned, 
but  slight  traces  of  inflammatory  conditions,  the  same  may  not  be  said  of  the 
articulations.  And  these  will,  in  turn,  be  profoundly  disturbed  in  their  func- 
tions according  to  the  extent,  duration,  and  character  of  the  inflammation, 
as  well  as  the  particular  joint  attacked. 

SURGICAL  FEVER 

In  speaking  of  the  participation  of  the  entire  organism  in  the  inflammatory' 
process  mention  has  been  made  of  fever.  This  is  the  most  important  of  the 
constitutional  symptoms  of  inflammation.  In  the  study  of  surgical  fever  it 
will  be  necessary,  in  order  properly  to  appreciate  all  of  its  phenomena,  to 
incpire  into  the  physiologic  regulation  of  the  temperature  of  the  body,  and 
the  principal  factors  concerned  in  this  regulation.     Of  these  the  most  important 


40 


INFLAMMATION 


are  (1)  the  reception  of  oxygen  b.y  the  blood-corpuscles,  and  the  subsequent 
process  of  oxidation  which  takes  place  in  the  tissues  and  blood ;  (2)  the  divi- 
sion of  the  appropriated  nutrient  materials  into  their  final  products  of  carbon 
dioxid,  water,  urates,  urea,  and  the  constituents  of  the  bile;  (3)  the  action 
of  the  muscles,  when  in  a  state  of  contraction  as  well  as  when  at  rest ;  (4)  the 
action  of  the  glands,  in  which,  during  the  process  of  secretion,  heat  is  set  free; 
(5)^  the  action  of  the  central  nervous  system.  The  most  important  ways  by 
which  heat  is  lost  to  the  body  are  (1)  through  the  skin  ;  (2)  through  the 
exhaled  air;  (3)  by  the  secretions  and  excretions  which  leave  the  body, 
notably  the  sweat,  urine,  and  feces. 

The  blood  is  the  balancing  medium  between  production  of  heat  and  loss  of 
heat.  As  the  circulating  fluid  passes  through  the  lungs  it  gives  off  a  portion 
of  its  heat  to  the  alveoli,  and  at  the  same  time  receives  oxygen,  which  becomes 
a  source  of  increased  heat  during  the  process  of  oxidation.  Thence  it  passes 
through  the  systemic  circulation,  parting  with  a  portion  of  its  caloric  in  the 
capillaries  of  the  skin,  because  of  its  proximity  to  the  surrounding  air.  In 
the  muscular  system  it  is  reinforced  by  the  metamorphoses  going  on,  only  to 
part  with  the  heat  again  at  some  other  point.  The  blood  therefore  furnishes 
oxygen  and  nutrient  material,  the  agents  necessary  for  the  active  performance 
of  the  functions  of  the  organs;  and,  in  addition,  it  equalizes  the  warmth  of 
the  different  organs,  thus  producing  a  uniform  temperature.  Inasmuch  as 
the  temperature  of  the  surrounding  atmosphere  differs  greatly  under  different 
circumstances,  it  becomes  evident  that  a  much  greater  loss  from  the  body  will 
take  place  at  one  time  than  at  another.  Though  the  temperature  of  the  body 
will  vary  slightly  under  normal  conditions,  yet  these  variations  are  incompar- 
ably less  than  those  which  take  place  in  its  surroundings.  It  is  therefore  evi- 
dent that  there  must  exist  some  means  within  the  body  itself  of  preventing 
at  one  time  too  great  a  production  of  heat,  and  at  another  too  great  a  loss. 
In  other  words,  there  must  be  some  physiologic  processes  instituted  for  the 
purpose  of  regulating  the  temperature  of  the  body. 

The  temperature  of  the  body  varies,  within  normal  limits,  between  98.3°  F. 
and  99.2°  F.  Normal  elevations  of  temperature  are  due  to  several  circum- 
stances, such  as  the  reception  of  food,  movements  of  the  body,  and  particu- 
larly vigorous  and  long-continued  muscular  exertion.  To  compensate  for 
variations  of  temperature  in  the  surrounding  air,  loss  of  heat  by  conduction 
and  radiation  is  to  a  certain  extent  limited.  Increase  of  the  temperature  in 
the  surrounding  air,  which  otherwise  Avould  lead  to  diminution  of  the  loss  of 
heat  from  the  hving  body,  is  balanced  by  a  simultaneous  dilatation  of  the 
arteries  of  the  skin.  This  causes  a  much  larger  quantity  of  blood  to  flow  to 
the  surface  and  hence  a  larger  quantity  of  caloric  is  parted  with  in  a  given  time. 
The  insensible  perspiration,  or  transpiration,  depending  on  increased  flow 
of  blood  to  the  surface  and  an  irritation  of  the  sweat-glands,  also  tends  to 
diminish  the  temperature  by  evaporation  from  the  surface.  Under  certain 
conditions  in  which  the  atmosphere  is  charged  with  moisture  accompanied 
by  a  high  temperature  (humidity) ,  greater  suffering  is  experienced  by  the  indi- 
vidual for  the  reason  that  the  moisture  from  the  surface  of  the  body  is  pre- 
vented from  evaporating;  on  the  other  hand,  a  dry  hot  air  is  easily  borne. 
Under  the  influence  of  surrounding  heat  the  body  is  rendered  unfit  for  exertion 
for  the  reason  that  all  unnecessary  movements  are  restrained  in  the  instinc- 


SURGICAL   FEVER  41 

ti\-e  desire  to  prevent  the  production  of  more  heat.  When  the  surrounding 
air  is  cooler  than  the  body,  regulation  of  the  temperature  is  accomplished  by 
means  of  the  contraction  of  the  arterioles,  whereby  the  amount  of  blood  pass- 
ing through  the  capillaries  of  the  skin  is  lessened,  and  the  loss  of  heat  decreased. 
The  impulse  to  increased  muscular  exertion  is  felt  which,  by  furnishing  an 
increased  amount  of  heat  to  compensate  for  that  which  is  lost,  o^'ercomes  the 
sensation  of  cold  experienced.  Whether  or  not  the  lowering  of  the  sur- 
rounding temperature  leads  to  more  rapid  metamorphosis  in  the  body  when 
at  rest,  is  an  open  question.  Experiments  on  this  point  have  given  con- 
flicting results;  on  the  one  hand,  careful  observation  seemed  to  show  that, 
under  the  influence  of  a  lower  temperature,  increased  elimination  of  carbon 
dioxid  took  place,  and  at  the  same  time  an  increased  appropriation  of  oxygen, 
while  seemingly  eciually  trustworthy  experiments  showed  the  reverse!  As 
far  as  the  increased  elimination  of  carbon  dioxid  is  concerned,  a  difficulty 
arises  in  that  it  is  impossible  to  determine  whether  this  is  due  to  a  more  rapid 
metamorphosis  and  a  consequent  formation  of  this  agent,  or  has  its  origin  in 
a  more  rapid  elimination  of  that  which  was  already  existing.  Again,  it  has 
been  shown  that  the  quantity  of  carbon  dioxid  given  off  is  not  proportionate 
to  the  decrease  of  the  surrounding  temperature,  and  that  the  reception  of 
oxygen  and  the  elimination  of  carbon  dioxid  do  not  occur  coincidentally  with 
the  rise  and  the  fall  of  temperature.  Liebermeister's  observations 
in  fever  patients  show  that  after  cold  baths  there  is  a  progressive  fall  in 
temperature  for  some  time  after  the  bath. 

The  nerves  of  the  skin  play  an  important  part  in  the  regulation  of  the 
body-temperature.  The  irritation  of  the  surface  of  the  body  "in  consequence 
of  changes  of  temperature  external  to  the  body  induces  reflex  action  along  the 
paths  of  the  vasomotor  nerves.  In  addition,  the  existence  of  special  heat- 
centers  has  been  suggested,  Avhich  regulate  the  production  of  body-heat.  Frac- 
tures of  the  middle  and  lower  cervical  vertebrae  and  contusions  of  the  spinal 
cord  in  this  region  have  been  followed  by  rapid  and  extreme  rise  of  tempera- 
ture. Experiments  by  N  a  u  m  y  e  r  and  Quincke  on  animals  showed 
rapid  rise  of  temperature  after  division  of  the  spinal  cord.  This  also  follows 
separation  of  the  medulla  oblongata  from  the  pons  ^'arolii.  I  have  seen  it 
follow  depressed  fracture  of  the  occipital  bone  with  extensive  laceration  of 
the  cerebellum.  The  latter  observation  suggests  the  presence  of  an  inhibit- 
ing heat-center  in  the  brain,  while  the  former  implies  the  presence  in  the  cer- 
vical portion  of  the  cord  of  inhibiting  fibers  from  a  center  in  the  brain  itself. 
E  u  1  e  n  b  u  r  g  and  B  r  o  w  n  -  S  e  q  u  a  r  d  demonstrated  on  animals  the 
fact  that  destruction  of  certain  portions  of  the  cortex  cerebri  resulted  in 
a  local  rise  of  temperature,  and,  in  addition,  in  a  like  effect  on  the  muscles 
supplied  from  the  centers  destroyed.  As  the  vasomotor  ner^'es,  both  those 
which  govern  the  constrictors  and  those  which  govern  the  dilators  of  the  ves- 
sels, pursue  almost  the  same  course  in  the  brain  and  spinal  cord  as  the  motor 
nerv^es,  the  effects  obtained  in  these  experiments,  as  well  as  in  the  case  of 
contusions  of  the  cord  itself,  may  have  been  due  to  irritation  or  paralysis 
of  these.  A  r  o  n  s  o  h  n  and  Sachs's  (1884)  experiments  were  instituted 
Anth  the  view  of  locating  a  heat-center  near  the  corpus  striatum.  An  increase 
of  temi^erature  followed  the  introduction  of  a  needle  at  this  point,  in  dogs 
and   rabbits,  but  the    same   criticism  will   also   apply  to  these  experiments. 


42  INFLAMMATION 

The  existence,  therefore,  of  either  a  heat-producing  or  an  inhibitory  center 
is  not  yet  proved;  according  to  our  present  knowledge,  the  vasomotor  system 
of  nerves  alone  serves  to  regulate  the  heat  of  the  body. 

The  febrile  state  is  undoubtedly  brought  about  by  a  disturbance  of  the 
balance  existing  bet^^'een  the  suppl}'  and  the  loss  of  heat  as  it  exists  in  the  nor- 
mal condition.  Whether  a  lessened  loss,  or  an  increased  production,  or  both, 
constitute  this  disturbance,  the  effect  is  the  same.  An  increase  in  the  tempera- 
ture of  the  body,  as  a  whole,  occurs,  and  a  condition  of  fever  results.  As  to  the 
first  of  these  propositions,  i.  e.,  a  lessened  loss  of  heat,  T  r  a  u  b  e  advanced 
the  theory  that  a  reflex  spasm  of  the  constrictor  muscular  apparatus  of  the 
superficial  circulation  resulting  from  vasomotor  disturbances  produced  a  dimi- 
nution of  the  amount  of  blood  at  this  point,  this  necessarily  leading  to  a 
diminished  loss  of  heat  from  the  skin,  and  causing  the  subjective  sensation  of 
chilliness  and  the  objective  rise  in  the  temperature  of  the  blood. 

C.  H  u  e  t  e  r  '  s  theory  somewhat  resembled  this,  except  that  the  lat- 
ter attributed  the  narrowing  of  the  lumina  of  the  vessels  to  conditions  existing 
in  the  blood,  which  lead  to  disturbances  of  function  in  circumscribed  areas, 
the  loss  of  heat  in  these  being  lessened,  while  in  others  an  actual  accumula- 
tion takes  place.  H  u  e  t  e  r  claimed  that  septic  infection  produced  such 
changes  in  the  blood  itself  that  in  these  limited  areas  retardation  or  complete 
stasis  took  place,  and  that  this  was  to  be  attributed  to  an  adhesion  of  the 
white  blood-corpuscles  to  the  inner  walls  of  the  vessels,  these  blood-corpus- 
cles containing  micrococci,  which  cause  obstruction  to  the  blood-current. 
Isolated  and  grouped  micrococci  likewise  appear  adherent  to  the  walls  of  the 
vessels,  obstructing  the  passage  of  the  red  blood-corpuscles. 

While  it  cannot  be  denied  that  in  cases  of  pronounced  or  profound  septic 
infection  such  conditions  as  H  u  e  t  e  r  describes  may  occur,  yet  it  is 
scarcely  probable  that  they  are  present  in  ordinary  surgical  fever.  On  the 
other  hand,  there  would  seem  to  be  some  foundation  for  T  r  a  u  b  e  '  s 
theory  that  accumulation  of  heat  within  the  body,  resulting  from  contrac- 
tion of  the  vessels  of  the  skin,  produces  the  general  condition  characteristic 
of  the  febrile  state.  For  instance,  during  the  stage  of  rigor,  or  even  chill,  the 
sensation  of  cold  referred  to  the  peripheral  portions  of  the  body  is  accompanied 
by  a  diminished  loss  of  heat  in  the  latter,  and  the  objective  symptom  of  rise 
of  temperature.  While  this  is  apparently  true  of  the  initial  stage  of  the  febrile 
attack,  it  is  likewise  true  that  when  the  fever  is  once  established  the  surface 
becomes  actually  hot,  and  gives  rise  to  an  increased  elimination  of  heat.  The 
thermometer  placed  in  the  axilla  of  a  fever  patient  will  rise  more  rapidly  than 
one  placed  in  the  axilla  of  a  healthy  person.  It  should  be  borne  in  mind  that, 
in  surgical  fever,  at  least  in  the  majority  of  cases,  the  occurrence  of  an  initial 
chill  is  either  not  marked  or  entirely  wanting.  L  e  y  d  e  n  has  shown  by 
calorimetric  measurements  carried  on  in  patients  suffering  from  remittent  fever, 
that  in  the  stage  of  fever  there  is  actually  a  much  larger  amount  of  heat 
eliminated  during  the  febrile  stage  than  during  the  normal  interval.  These 
are  confirmed  by  L  i  e  b  e  r  m  e  i  s  t  e  r  '  s  experiments,  and  by  W  a  h  1 , 
Senator,  and  others. 

Neither  T  r  a  u  b  e  '  s  theory  nor  H  u  e  t  e  r  '  s  modification  is  suf- 
ficient to  account  for  the  indubitable  fact  that  in  the  febrile  state  there  is  an 
increased  production  of  heat.     That  this  results  from  an  increased  tissue 


SURGICAL    FEVER  43 

metamorphosis  there  can  now  be  but  httle  doubt.  L  i  c  b  e  r  m  e  i  s  t  e  r 
and  Leyden  lia\-c  both  shown  that  the  ehmination  of  carbon  dioxid 
with  the  exhaled  air  is  much  increased  chiring  the  febrile  state.  The  ciuan- 
tit>'  inci'eases  in  direct  proportion  to  the  rise  of  temperature,  but  the  increased 
elimination  ceases  or  subsides  more  rapidly  than  the  temperature.  This  is 
in  part  accounted  for  by  the  fact  that  the  respirations  become  more  shallow 
when  the  fever  is  at  its  height.  In  addition  to  this,  it  has  been  demonstrated 
that  an  increased  amount  of  oxygen  is  consmned  in  the  febrile  state,  and 
that  consequently'  an  increased  oxidation  takes  place.  To  this  is  to  be 
attributed  the  presence  of  increased  heat,  Avhich  raises  the  temperature  of 
the  body. 

Increased  metaiiiorphosis  in  fever  patients  is  hkewise  shown  by  the  greater 
quantity  of  urea  eliminated,  the  increase  of  urea  precechng  the  attack  of  fever. 
This  would  seem  to  suggest  that  decomposition  of  the  albuminates  takes  place 
before  the  ele\'ation  of  temperature,  and  that  this  decompositiozi  is  not  the 
result  but  rather  the  cause  of  the  fever.  Other  constituents  of  the  urine 
are  likewise  increased.  How  far  the  formation  and  secretion  of  water  are 
increased  or  diminished  in  fever  can  scarcely  be  determined  by  experiment,  from 
the  fac't  that  water  leaves  the  body  through  many  channels.  That  which  is 
separated  by  means  of  the  kidneys  is  usually  diminished,  as  well  as  that  which 
is  eliminated  through  the  skin,  as  shown  by  the  dry  skin  of  fever  patients. 
The  amount  of  water  eliminated  by  the  lungs  as  well  as  the  amount  elimi- 
nated by  the  perspiration,  particularly  during  the  sweating  state  of  the  fever, 
is  markedly  increased,  but  this  is  compensated  for  by  an  increased  production 
of  water  in  the  tissues.  In  the  decomposition  of  nitrogenous  as  Avell  as  of 
nonnitrogenous  substances  water  is  formed  by  the  addition  of  oxygen  to  the 
released  hvdrogen.  An  augmentation  of  these  processes  during  the  febrile 
state  would  therefore  lead  to  the  greater  production  of  water. 

This  increased  formation,  however,  does  not  apparently  equal  the  demand 
on  the  part  of  the  system  for  fluids  to  compensate  for  the  loss  occurring  during 
the  existence  of  the  fever.  Else  how  are  we  to  account  for  the  urgent  thirst, 
the  dry  skin,  the  parched  lips  and  tongue  of  fever  patients  ?  Lavoi- 
sier's view  that  the  oxygen  combining  with  hydrogen  is  derived  for  the 
greater  part  from  the  carbohydrates  of  the  fat  explains  the  rapid  disappear- 
ance of  the  latter  during  the  febrile  state  or  under  circumstances  involving 
the  occurrence  of  profuse  sweating. 

The  relations  existing  between  surgical  fever  and  augmented  meta- 
morphosis are  important,  and  deserve  special  consideration.  The  connec- 
tion between  the  changes  which  occur  in  the  wound  and  the  patient's  general 
condition  is  now  well  known.  The  most  casual  observer  cannot  fail  to  note 
that  with  the  first  occurrence  of  putrefaction  in  the  wound,  a  rise  of  the  gen- 
eral temperature  takes  place,  and  increases  with  the  advance  of  an  acute 
abscess,  facts  too  well  known  to  require  more  than  casual  mention  here. 
These  facts  are  suggestive  of  but  one  theory  to  account  for  their  occurrence 
in  connection  with  each  other.  The  wound  itself  must  contain  the  noxious 
agent  which  produces  the  rise  of  temperature,  and  this  agent  must  be  pyro- 
genic  to  the  entire  body. 

The  question  as  to  the  character  of  the  agents  which  serve  as  etiologic 
factors  in  the  production  of  surgical  fever  has  long  been  a  troublesome  one. 


44  INFLAMMATION 

G  a  s  p  a  r  d  in  1SS2,  and  subseqnently  ]\f  a  g  e  n  d  i  e  ,  S  e  d  i  1 1  o  t  ,  and 
others,  demonstrated  that  injection  of  putrid  material  under  the  skin  or  into 
the  veins  of  animals  invariably  produced  fever.  Endeavors  to  isolate  an  active 
principle  of  a  chemic  nature  from  the  putrid  material  were  only  partially 
successful  (Bergmann's  sepsin).  A  fresh  impulse  was  given  to  the 
investigation  Avhen  the  role  -which  microorganisms  play  in  the  production  of 
wound  infection  was  properly  understood  and  their  presence  demonstrated 
in  the  blood  itself.  The  action  of  the  bacteria  on  organic  substances  was 
already  known.  It  remained  only  to  appreciate  at  its  true  value  the  fact 
that  the  infectious  agents  or  toxic  principles,  the  so-called  ptomains,  depend 
on  the  vital  processes  of  these  microorganisms. 

Advanced  methods  in  bacteriologic  research  and  increased  knowledge  as 
to  the  pathogenic  character  of  certain  microorganisms  have  year  by  year  con- 
firmed the  opinion  that  the  presence  of  bacteria  in  the  tissues  or  the  blood  itself, 
or  in  both,  produces  not  only  inflammation  but  also  fever.  At  the  present 
day  it  is  generally  held  that  the  rise  of  temperature  following  the  inflic- 
tion of  a  wound  depends  on  soluble  poisons,  the  ptomains,  which,  acting 
as  pyrogenic  agents,  exert  a  general  influence  on  the  body  either  through 
the  nervous  system  or  by  way  of  the  lymph-channels  and  blood-channels. 
These  agents  may  exert  their  influence  (I)  by  irritating  the  peripheral  nerves, 
which  in  turn  affect  the  central  ner^'ous  system  by  reflex  action;  (2) 
by  being  taken  up  through  the  last-mentioned  channels,  passing  into  the  gen- 
eral circulation,  and  being  transferred  thence  into  the  tissues  of  the  body, 
where  by  their  presence  an  increased  metamorphosis  is  excited. 

It  cannot  be  denied  that  such  a  thing  as  fever  from  reflex  irritation  may 
exist.  Clinical  observation  supports  this  view.  The  condition  kno^\-n  as  ure- 
thral fever  has  been  so  classed.  Even  in  these  cases  it  must  be  admitted  that 
the  microorganisms  which  invariably  inhabit  the  meatus  urinarius  may  have 
been  of  a  septic  nature  and  may  have  been  carried  b}^  the  sterilized  sound  into 
the  deeper  parts  of  the  urethra,  there  producing  their  appropriate  phenomena. 
It  is  certain,  however,  that  in  the  great  majority  of  cases  urethral  fever  can 
be  prevented  by  the  administration  of  a  full  dose  of  opium.  It  is  also  a  clini- 
cal fact  that  the  treatment  of  a  stricture  by  gradual  clilatation  of  the  urethra 
will  sometimes  be  followed  by  a  chill  subsequent  to  each  introduction  of  the 
sound.  But  in  the  fever  following  wounds  the  course  of  the  symptoms  and  the 
conditions  present  differ  greatly  from  those  mentioned  above.  In  the  case  of 
wound  fever  the  appearance  of  the  fever  is  deferred  for  from  twenty-four  to 
forty-eight  hours,  while  in  the  case  of  urethral  fever  the  rise  of  temperature  rap- 
idly follows  the  passage  of  the  sound.  This  makes  it  very  improbable  that 
the  two  conditions  originate  in  the  same  way.  It  has  been  suggested,  however, 
that  the  toxic  material  develops  earlier  in  one  case  than  in  the  other,  but 
that  in  both  its  influence  is  exerted  reflexly  through  peripheral  nerve  irri- 
tation. Tetanus  has  been  cited  as  a  wound  disease  which  has  its  origin  in 
a  peripheral  nerve  disturbance.  However,  in  the  light  of  modern  research  and 
the  work  of  Nicolaier,  Kitasato,  and  others,  tetanus  has  been 
sho^vn  to  be  due  to  a  specific  ptomain,  the  result  of  bacterial  infection. 
Likewise  if  the  nerve-trunks  of  a  limb  are  resected,  reflex  disturbances  being 
thi;s  rendered  impossible,  suppuration  artificially  produced  in  the  part  deprived 
of  innervation  still  produces  all  the  phenomena  of  fever.     On  the  other  hand, 


SURGICAL   FEVER  45 

the  injection  of  putrid  material  into  the  veins  is  invariably  followed  b}'  similar 
febrile  symptoms. 

There  can  be  no  question  but  that  the  central  nervous  system  is  more  or 
less  disturbed  in  the  febrile  condition.  This  is  evinced  by  the  muscular  trem- 
bling that  occurs  during  a  chill,  and  by  the  convulsive  attack  which  is  so  fre- 
quently the  precursor  of  a  febrile  attack  in  children.  The  cerebral  disturbance, 
the  psychic  irritation,  and  the  excessive  sensibility  are  all  the  consequences  of 
the  introduction  into  the  blood  of  the  p^rogenic  agent.  That  the  vasomotor 
nerves  participate  more  or  less  in  this  general  disturbance  is  shown  by  the 
alternate  flushing  and  pallor  of  the  surface  and  the  varying  sensations  of  heat 
and  cold.  These  latter  symptoms,  however,  are  rather  a  part  of  the  general 
effects  of  the  morbific  agent  and  not  a  cause  of  the  fever,  since  it  has  not  yet 
been  shown  that  the  vasomotor  disturbances  result  in  an  augmentation  of 
tissue  metamorphosis  and  increased  heat-production. 

It  has  already  been  stated  that  the  muscles  and  glands  are  the  chief  sources 
of  heat  in  the  normal  condition.  Increased  irritation  of  these  structures  was 
thought  to  be  the  source  of  the  increased  heat  of  fever.  B  e  c  q  u  e  r  e  1  , 
H  e  1  m  h  o  1 1  z  ,  B  e  cl  a  r  d  ,  L  u  d  w  i  g  S  p  e  i  s  s  ,  H  e  i  d  e  n  h  a  i  n  , 
and  K  0  r  n  e  r  ,  ho'\\'ever,  made  a  series  of  thermo-electric  measu.rements 
in  animals  in  which  fever  had  been  artificially  produced,  and  demon- 
strated that  even  in  inactive  conditions  of  the  muscles  heat  production  is 
increased,  as  shown  by  an  elevation  of  temperature  in  the  adductor  muscles  and 
in  the  blood  of  the  common  iliac  vein,  as  compared  with  that  in  the  left  heart. 
The  same  increased  heat  production  is  believed  to  take  place  in  the  glands. 
In  the  case  of  the  muscles  this  is  thought  to  be  due  to  the  so-called  "  insen- 
sible innervation"  the  result  of  the  irritation,  and  in  the  case  of  the  glands  to 
the  irritation  of  the  ner^'es  regulating  secretion. 

Neither  direct  irritation  of  the  nerve-centers  nor  vasomotor  disturbances 
are  sufficient  to  account  for  the  increased  metamorphosis  occurring  in 
fever.  As  to  the  direct  influence  of  the  pyrogenic  agent  on  the  blood  and 
tissues,  there  is  during  a  febrile  attack  an  evident  increase  in  the  coloring- 
matter  of  the  urine,  due  to  the  augmented  decomposition  of  the  red  blood- 
corpuscles.  This  destruction  occurs  to  a  still  greater  extent  in  highly  septic 
conditions,  and  constitutes  the  so-called  hematogenous  icterus.  The  diminu- 
tion of  fibrin  is  likewise  noticeable.  Boeckmann  demonstrated  by 
actual  count  the  relative  diminution  of  the  red  blood-corpuscles  during  the 
fcA'er  stage  of  an  intermittent  fever,  as  compared  ^vith  the  number  existing 
in  the  interval.  Certainly  no  nerve  interference  can  be  said  to  be  possible 
here. 

"VMiat  occurs  in  the  blood  without  nerve  influence  can  occur  in  the  tissues 
to  which  the.  pyrogenic  agent  is  conveyed  by  the  circulation.  The  character 
of  this  agent,  as  well  as  that  of  the  tissues  with  which  it  comes  in  contact, 
antU  govern  in  great  measure  the  extent  of  the  effect  produced,  just  as  specific 
phenomena  are  observed  to  follow  the  introduction  of  such  soluble  poisons  as 
strychnin,  curare,  and  ergotin  in  the  muscular  apparatus,  and  mercury  in  the 
glandular  structures.  The  presence,  on  the  one  hand,  of  a  ptomain  or  amor- 
phous ferment  in  the  blood  and  tissues,  and,  on  the  other,  of  the  bacteria 
themselves,  wiU  determine  the  extent  and  character  of  the  changes  produced 
in  the  organism.     As  far  as  the  bacteria  themselves  are  concerned,  these,  cir- 


46  INFLAMMATION 

dilating  in  the  blood,  may  accumulate  in  certain  places,  notably  in  the  larger 
glandular  organs,  such  as  the  kidneys,  spleen,  and  liver,  and  also  in  the  medul- 
lary structures  of  bones.  The  free  supply  of  blood  to  these  structures  carries 
the  microorganisms  there  in  great  numbers,  Avhere  either  the  retardation  of 
the  blood-current  or  the  presence  of  a  terminal  circulation  causes  their  accu- 
mulation. Increased  metamorphosis  results  from  the  irritation  Avhich  their 
presence  excites,  and  this,  in  turn,  increases  the  production  of  heat.  This 
fact  explains  the  rise  of  temperature  observed  by  H  e  i  d  e  n  h  a  i  n  and 
K  o  r  n  e  r  in  the  common  iliac  vein. 

Finally,  the  increased  production  of  heat  due  to  the  inflammation  itself 
is  not  to  he  lost  sight  of,  for  although  it  cannot  alone  explain  the  whole  phe- 
nomena of  fever,  as  suggested  by  Z  i  m  m  e  r  m  a  n  n  and  by  most  of  the 
older  writers,  yet  its  co-operative  influence  is  not  to  be  denied.  It  is  scarcely 
probable  that  the  multiplication  of  cellular  elements  and  the  increased  move- 
ments of  the  leukocytes  can  be  accomplished  without  the  production  of 
increased  heat. 

Experimental  research  and  clinical  observation,  therefore,  justif}^  the  fol- 
lowing definition:  Fever  is  an  increased  tissue  metamorphosis,  the  essential  result 
of  the  influence  of  pathogenic  bacteria.  This  influence  may  be  exerted  directly  by 
the  presence  of  the  jnicroorganisms  themselves,  or  indirectly  by  the  products  of 
decomposition  and  the  presence  of  ptomains.  In  addition,  there  are  present  irri- 
tations of  the  sensory  and  motor  nerve-centers,  particularly  of  the  vasomotor 
nerves,  the  disturbances  of  which  cause  temporarily  decreased  elimination 
and  increased  irritability  of  the  nerves  of  the  vessels. 

The  Respiration  and  Pulse  in  Fever.— As  fever  represents  increased 
tissue  metamorphosis,  it  follows  that  there  will  be  an  augmentation  in  the  pro- 
duction of  carbon  dioxid  and  a  demand  on  the  part  of  the  system  for  more 
oxygen.  This  can  be  supplied  only  by  more  rapid  respirations  and  an  accele- 
rated circulation.  The  necessity  for  the  latter  is  still  further  increased  by  a 
diminution  in  the  number  of  red  blood-corpuscles,  the  oxygen-carriers  of  the 
blood.  The  production  of  an  increased  amount  of  heat  also  increases  the  num- 
ber of  respirations,  together  with  the  pulse-rate,  this  increase  occurring  inde- 
pendently of  tissue  changes.  Irritation  from  want  of  oxygen  likewise  disturbs 
the  centers  of  respiration  and  circulation.  While  either  the  want  of  ox^-gen 
or  the  increased  heat  may  in  some  cases  act  as  direct  irritating  causes,  in 
other  instances  the  direct  action  of  the  pyrogenic  agent  may  be  the  stimu- 
lant to  the  nerve-centers.  This  is  probable  from  the  fact  that  other  abnor- 
mal qualities  of  the  pulse,  such  as  dicrotism,  may  occur  in  fever.  This 
phenomenon  results  from  a  relaxation  of  the  wall  of  the  vessel  and  a  conse- 
quent decrease  in  arterial  tension.  Sphygmographic  tracings  in  connection 
with  animals  which  had  inhaled  nitrite  of-  amyl,  or  had  been  injected  wdth 
atropin,  showed  dicrotic  tracings.  It  has  also  been  claimed  by  some  observers 
that  almost  every  form  of  fever  produces  characteristic  and  peculiar  changes  in 
the  pulse,  those  produced  by  traumatic  fever  differing  from  those  produced 
by  erysipelas,  those  produced  by  intermittent  fever  differing  from  those  pro- 
duced by  remittent  fever,  all  these  in  turn  differing  from  one  another  and 
from  the  pulse  observed  in  the  exanthemata. 

In  simple  traumatic  fever  pathologic  changes  in  parenchymatous  organs 
are  scarcely  ever  observed.     In  the  fever  of  wound  diseases,  however,  they 


SURGICAL   FEVER  47 

do  occur,  and  will  bo  described  in  that  connection.  It  is  sufficient  to  mention 
here  that  these  changes  may  depend  on  the  presence  of  heat.  But  this  fact 
will  not  of  itself  suffice  to  explain  these  phenomena.  It  has  been  observed 
that  special  and  peculiar  degenerations  follow  the  administration  of  specific 
poisons,  as  phosphorus  and  arsenic.  In  the  same  manner  the  specific  action 
of  certain  pathogenic  bacteria  may  produce  characteristic  and  peculiar  lesions. 
This  has  been  demonstrated  by  experiments  made  by  Koch,  C  .  V  o  i  t , 
and  others.  Animals  whose  secretions  after  several  days  of  hunger  remained 
unaffected,  were  subjected  to  artificial  heat.  The  decomposition  of  albumin- 
ous elements  was  not  thereby  affected. 

Resorptive  or  Aseptic  Fever. — Traumatic  or  wound  fever,  as  it  is 
sometimes  called,  is  caused,  as  has  been  shown,  by  a  pyrogenic  agent  which 
has  its  origin  in  a  wound  whose  secretions  have  undergone  putrefaction  and 
become  putrid.  This  is  to  be  distinguished  from  another  form  of  fever  pro- 
duced by  the  passage  of  dead  tissue  into  the  blood,  the  further  destruction  and 
oxidation  of  which  occurs  without  the  bacteria  of  putrefaction.  This  is  known 
as  aseptic  fever,  or  the  fever  of  resorption  (Volkmann).  It  is  anal- 
ogous to  that  which  follows  intravenous  infusion  of  solution  of  sodium 
chlorid,  transfusion  of  the  blood  of  animals,  and  experimental  fever  resulting 
from  intravenous  injections  of  flour  and  water,  etc.  Like  these,  aseptic  or 
resorptive  fever  is  characterized  by  rapid  onset  and  short  duration,  which 
distinguish  it  from  wound  fever  proper.  Volkmann  pointed  out 
the  analogy  existing  between  this  fever  and  that  which  is  observed  to  follow 
simple  fractures,  which  results  from  resorption  of  effused  blood  in  large 
quantities.  The  blood  is  overfilled  with  dead  albuminous  substances,  originat- 
ing from  the  extravasated  blood,  its  broken-down  corpuscles  and  other 
detritus,  and  an  increased  process  of  oxidation  is  rendered  necessary  to  dis- 
pose of  it. 

The  transformation  of  the  albuminous  substances  which  accumulate  in 
the  blood  in  aseptic  fever  is  probably  due  to  ferments  already  existing,  and 
not  introduced  from  without.  Resorptive  fevers  and  even  death  from  exten- 
sive coagulation  of  blood  in  the  vessels  occurs  after  the  injection  into  the  veins 
of  animals  of  Schmidt's  fibrin  ferment,  a  substance  obtained  from 
defibrinated  blood  itself.  Some  of  the  digestive  ferments,  such  as  pepsin  and 
pancreatin,  will  likewise  produce  similar  results.  Whether  the  wound  is  acci- 
dental or  operative,  aseptic  fever  occurs  when  the  blood  escapes  into  the  wound 
cavity,  or  when  the  particles  of  broken-dowTi  tissue,  with  the  effused  blood, 
undergo  resorption.  It  is  claimed  for  these  resorbed  products  that  they  are 
but  slightly  altered  from  their  normal  condition,  not  having  undergone  putre- 
factive or  other  changes,  and  that  the  fever  resulting  from  their  presence  should 
not  be  confounded  with  febrile  conditions  associated  with  well-kno\Mi  putre- 
factive changes  and  included  under  the  general  term  of  sepsis.  The  necrosis 
of  tissue  may  be  the  result  of  the  antiseptic  agent  employed  as  well  as  the 
result  of  the  damage  done  to  the  tissues  by  the  traumatism  inflicted. 

Resorptive  or  aseptic  fever  may  follow  the  injury  within  a  few  hours,  and 
is  usually  of  short  duration,  rarely  lasting  beyond  the  third  day.  The  tempera- 
ture may  rise  from  one  to  three  degrees  above  the  normal.  This  fever  does  not 
produce,  as  does  septic  fever,  a  profound  impression  on  the  sensorium,  nor 
do  the  patients,  as  a  rule,  complain  greatly  of  discomfort  from  its  presence. 


48  INFLAMMATION 

The  appetite  is  not  usually  affected.  These  points,  as  well  as  the  fact  that 
it  subsides  at  about  the  time  when  septic  fever  begins,  distinguish  it  from  the 
latter,  into  which,  however,  it  may  imperceptibly  merge.  It  is  questionable 
if  the  term  "aseptic  fever"  is  admissible  as  applied  to  this  condition,  for  the 
reason  that  the  changes  described  as  occurring  in  the  effused  products  of 
inflammation  and  the  debris  of  the  wounded  surfaces,  as  compared  with  the 
changes  of  putrefaction,  are  differences  of  degree  rather  than  of  kind. 


TREATMENT  OF  INFLAMMATION 

The  preventive  treatment  of  suppurative  inflammation  consists  in  main- 
taining in  an  aseptic  condition,  as  far  as  possible,  the  part  injured  or  diseased. 
The  curative  treatment  will  include  the  employment  of  antiseptic  measures. 
In  the  majority  of  accidentally  inflicted  wounds  the  germs  of  putrefaction 
gain  admission  to  the  effused  kood  and  lymph,  where,  under  the  favorable 
influences  of  heat  and  moisture,  and  in  the  presence  of  a  proper  pabulum,  thev 
proliferate.  Under  these  circumstances  a  thorough  disinfection  of  the  parts 
will  be  necessary-  in  order  to  protect  the  patient  from  the  effects  of  the  noxious 
agents  which  have  infected  the  wound.  This  process  of  disinfection  consti- 
tutes the  antiseptic  treatment  of  wounds. 

Failure  to  establish  or  to  maintain  a  rigidly  aseptic  condition  in  operation 
wounds  may  permit  them  to  become  infected  to  as  dangerous  an  extent  as 
those  accidentally  inflicted,  and  may  require  antiseptic  measures  in  the  after- 
treatment.  Under  some  circumstances  it  may  be  difficult  or  impossible  to 
accomplish  even  a  relative  asepsis.  Probably  such  a  thing  as  absolute  asepsis 
is  not  attainable.  On  account  of  the  minute  character  and  general  dissemina- 
tion of  the  germs  of  putrefaction  it  is  beyond  the  possibilities  of  human  skill 
and  foresight  to  close  effectually  every  channel  to  their  entrance.  But,  fortu- 
nately, the  serum  of  the  blood  is  itself  a  germicide  which  will  protect  the  tis- 
sues, and,  unless  too  heavily  invaded,  will  enable  them  to  withstand  the  effects 
of  lesser  degrees  of  putrefaction  and  germ  proliferation.  Different  tissues,  as 
well  as  individuals  as  a  whole,  may  possess  varying  powers  of  resistance,  and 
the  question  of  infection  will  depend  on  (1)  a  greater  or  lesser  dosage;  (2) 
the  degree  of  local  or  general  vital  resistance. 

Finally,  in  some  individuals,  the  victims  of  accidentally  inflicted  wounds 
or  the  subjects  of  cutting  operations,  the  organism  already  contains  noxious 
agents  which  may  be  transported  to  the  wound  and  give  rise  to  disturbances 
more  or  less  pronounced,  independent  of  local  sources  of  infection.  This, 
however,  is  comparatively  rare.  As  a  rule,  the  more  rigid  the  enforcement 
of  aseptic  precautionary  measures  in  operation  wounds,  on  the  one  hand, 
and  the  earlier  and  more  persistent  the  application  of  antiseptic  measures  in 
wounds  that  have  become  septic  on  the  other,  the  better  the  results. 

Aseptic  Operative  Teclinic. — This  consists  in  the  employment  of 
methods  which  will,  as  far  as  possible,  sterilize  the  site  of  the  wound  and 
all  articles  which  are  likely  to  come  in  contact  with  it,  together  with  the  hands 
and  person  of  the  surgeon  and  his  assistants.  Experiments  have  sho^^TL  that 
a  large  number  of  pathogenic  bacteria  have  their  habitat  on  the  cutaneous  sur- 
face of  the  body  (C  h  e  y  n  e).  Others,  which  are  less  virulent,  but  which  may 
become  actively  pathogenic  under  conditions  of  lessened  local  vital  resistance. 


THE    TREATMENT    OF    INFLAMMATION  49 

such  as  Staphylococcus  epidermidis  albus  (Welch),  are  also  present, 
in  addition  to  others  that  are  positively  harmless.  Only  criminal  careless- 
ness will  permit  a  surgeon  to  make  an  incision  into  integument  which  has  not 
been  deprived,  as  far  as  possible,  of  lurking  sources  of  danger.  No  disinfec- 
tion or  sterilization  of  instruments,  care  in  the  operative  technic  nor  appli- 
cation of  antiseptic  dressings  can  compensate  for  failure  in  this  respect. 

The  Preparation  of  the  Patient. — This  consists  in  giving  a  general  bath 
about  twelve  hours  before  the  operation,  and  scrubbing  that  portion  of  the 
surface  of  the  body  in  the  neighborhood  of  the  proposed  operation  which  is 
likely  to  be  exposed  in  the  operating  field,  with  a  bristle  hand-brush 
and  strongly  alkaline  soap  (sapo  viridis  of  the  Pharmacopoeia)  and  warm  water. 
The  parts  are  shaved,  rinsed,  and  covered  with  a  compress  wetted  Avith  the 
borosalicylic  solution  of  Thiersch  (salicylic  acid,  1 5  grains ;  boric 
acid,  90  grains;  water,  a  pint),  covereci  with  oiled  silk  and  bandaged  carefully  in 
place.  The  object  of  this  application  is  the  further  separation  of  the  dead 
epithelium;  the  power  of  salic3'lic  acid  in  effecting  this  separation  is  well 
known.  After  the  patient  is  anesthetized  the  compress  is  removed  and  the 
parts  again  washed  with  soap  and  water,  a  bunch  of  gauze  being  substituted 
for  the  brush.  This  second  scrubbing  is  followed  by  rinsing  with  95  per  cent 
alcohol  and  then  with  ether,  to  remove  the  secretions  of  the  glandular  appa- 
ratus of  the  skin  excited  by  the  manipulation,  which  of  themselves  contain 
microorganisms.  The  skin  is  now  freely  moistened  with  a  1  :  2000  solution 
of  sublimate  in  50  per  cent  alcohol,  which  is  allowed  to  dr}-  on  the  surface. 
On  parts  already  in  an  inflamed  condition,  and  in  connection  with  which  it 
is  difficult  to  employ  the  scrubbing  process,  solutions  of  carbolic  acid,  2  to  3 
per  cent,  because  of  their  well-kno^^Ti  power  to  penetrate  through  the  epidermis 
into  the  cutis,  may  be  applied,  and  the  more  vigorous  cleansing  measures 
postponed  until  the  patient  is  anesthetized. 

The  mouth,  pharyngeal  cavity,  female  genitals,  rectum,  and  bladder 
require  special  care  in  the  preparation.  The  mouth  and  pharyngeal  cavities 
are  cleansed  for  a  day  or  two  before  the  operation  b}-  frequent  rinsings  and 
garglings  with  a  1  per  cent  solution  of  chlorate  of  potassium  or  a  wdne-colored 
solution  of  permanganate  of  potassium.  The  teeth  are  to  be  brushed  vigorously 
with  a  stiff  toothbrush  and  all  tartar  removed.  I'lceration  and  suppurative 
conditions  are  to  be  allowed  to  heal,  if  possible.  Carious  teeth  should  be 
removed.  The  vagina  should  be  douched  for  a  day  or  two  before  the  operation 
^^ith  a  warm  borosalicylic  solution,  or  a  2  per  cent  carbolic  acid  solution,  and 
tamponed  with  iodoform  gauze.  Immediately  before  the  operation  it  should 
be  cleansed  ^ith  gauze  and  soapsuds,  and  afterward  irrigated.  If  putrefy- 
ing processes  are  present  (e.  g.,  breaking  doA\Ti  carcinoma  of  the  cervix),  the 
diseased  tissues  are  to  be  curetted  away  and  the  surface  cauterized  with  the 
thermocauter)\  In  operations  in  and  about  the  rectum  the  patient  should 
be  restricted  to  a  fluid  diet  and  the  bowels  kept  free  by  salines,  aided  by 
enemas  of  glycerin  and  water,  for  a  day  or  two  beforehand.  During  the 
operation,  after  the  lower  bowel  has  been  cleansed,  the  upper  part  of  the 
rectum  is  tamponed  with  gauze.  After  the  operation,  unless  some  contrain- 
dications exist,  bowel  movements  are  to  be  prevented  for  several  days  or  a 
week  by  the  judicious  use  of  opium.  If  cystitis  is  present,  the  bladder 
should  be  frequently  irrigated  with  a  2  per  cent  solution  of  salicylic  acid  or 
the  borosalicvlic  solution  of  Thiersch  (see  above). 
5 


50 


INFLAMMATION 


Provision  against  reinfection  is  made  by  covering  the  patient  with  a  steril- 
ized sheet  that  has  an  opening  admitting  access  to  the  field  of  operation,  and, 
in  addition,  a  number  of  sterilized  towels  are  pinned  carefully  over  the  sheet. 
Unless  the  head  is  the  part  to  be  operated  on,  a  towel  should  be  placed  upon 
it,  turban  fashion,  to  confine  the  hair. 

The  Preparation  of  the  Surgeon  and  His  Assistants. — The  outer  street 
clothing  of  the  surgeon  and  his  assistants  is  removed,  and  a  freshly  laun- 
dered white   linen   suit  substituted.     After  all  other  preparations  are  com- 


FiG.  5. — Schimmblbdsch's  Sterilizer  for  Boiling  Instruments  in  Soda  Solution. 

pleted  this  is  covered  Avith  a  linen  gown,  steam-sterilized,  the  sleeves  of 
which  fit  closely  to  the  forearm  and  stop  just  below  the  elbow.  The 
head  is  covered  b}'  a  linen  cap  such  as  bakers  wear,  or  an  improvised 
turban  made  from  a  towel.  No  beard  should  be  worn;  at  the  most  a 
mustache    is    permissible,  and    this    is  disinfected    by    a    sublimate    solution 


Fig.  6. — Scalpel  Rack  and  Case. 


before  each  operation.  The  nostrils  and  mouth  should  be  co\'ered  with  a  mask 
of  cheese-cloth  to  prevent  the  expulsion  of  infectious  material  in  speaking, 
or  accidentally  coughing  or  sneezing.  The  hands,  and  particularly  the  sub- 
ungual spaces,  are  the  constant  habitat  of  pyogenic  organisms  and  require 
special  caie.  The  finger-nails  should  be  kept  closely  trimmed.  The  hands 
must  be  scrubbed  with  a  hand-brush  and  soap  and  running  water  for  at  least 
three  minutes,  particular  attention  being  paid  to  the  fmger-tips;    the  nail 


THE   TREATMENT   OF   INFLAMMATION 


51 


spaces  are  finally  rubbed  with  gauze  moistened  with  a  1 :  2000  solution  of  sub- 
limate in  50  per  cent  alcohol  and  rinsed  in  a  I:  2000  watery  sublimate  solution. 
They  are  then  immersed  in  a  1:  2000  solution  of  sublimate  to  which  has  l)ecn 
added  potassium  i)ermano;anate  to  saturation,  until  they  are  deeply  stained. 
The  hands  should  not  be  scrubbed  too  vigorously,  since  the  irritation  thus  pro- 
duced will  lead  to  prompt  reinfection  of  the  surface  from  the  passage  of  micro- 
organisms from  the  depths  of 
the  skin.  This  will  be  still 
further  enhanced  by  slight 
abrasions.  If  the  hands  re- 
main stained  with  the  perman- 
ganate sublimate  solution,  the 
surface  is  in  a  measure  protected 
from  reinfection  from  bacteria 
residing  in  the  skin  itself.  After 
the  operation  is  completed  the 
stain  is  remo\'ed  by  immersing 
in  a  saturated  solution  of  ox- 
alic acid.     If   the  sapo  viridis 


Fig.  7. — Arnold  Steam  Sterilizek. 


Fig.  8. — Hospital  Steam-pressure  Sterilizer,  Instru- 
ment Boiler,  and  Water  Sterilizer. 


of  the  German  Pharmacopoeia  is  used,  both  before  and  after  the  operation, 
the  hands  will  not  suffer  from  eczematous  eruptions.  Or,  the  hands  may  be 
stained  in  a  saturated  solution  of  permanganate  after  they  are  scrubbed,  and 
this  removed  at  once  by  the  oxalic  acid  solution  (K  e  1 1  y) .  The  oxalic  acid 
itself  is  a  potent  factor  in  the  sterilization.  When  the  hands  have  been  re- 
cently exposed  to  pus  organisms,  this  course  should  be  followed,  and  the  hands 
restained  in  the  permanganate  sublimate  solution  above  mentioned.     Another 


52 


INFLAMMATION 


method  is  to  Avash  the  hands  with  ether  and  alcohol  after  scrubbing,  and  to 
immerse  them  for   five    minutes    in    sublimate    solution   (F  ii  r  b  r  i  n  g  e  r). 

Experiments  have  shown  simple  soap 
and  water  cleansing  to  be  inefficient 
(Bole).  The  aseptic  condition  of  the 
hands  must  be  maintained  during  the 
operation  by  occasionally  rinsing  them, 
first  in  a  watery  sublimate  solution,  and 
then  in  alcohol.  They  are  dried  on  a 
sterilized  towel  before  being  brought  in 
contact  with  the  wound. 

Disinfection  of  Instruments. — The 
simplest  and  at  the  same  time  the  most 
trustworthy  plan  is  to  boU  the  instru- 
ments for  five  minutes  in  a  1  per  cent  so- 
lution of  the  alkaline  carbonate  of  soda 
(sal.  soda  of  commerce).  They  are  after- 
ward placed  in  trays  which  have  been 
boiled  in  the  soda  solu  tion  and  filled  with 
a  cold  boiled  soda  and  carbolic  acid  solu- 
tion, 1  per  cent,  S  c  h  i  m  m  e  1  b  u  s  c  h 
(Fig.  5).  In  the  absence  of  suitable  trays 
the  instruments  maj^  be  placed  on  steril- 
ized towels  and  covered  with  them.  The 
latter  method  is  preferred  by  many  oper- 
ators. During  the  operation  the  instru- 
ments are  rinsed,  when  soiled,  in  boiled 
water,  or  a  2  per  cent  carbolic  solution. 
After  use  they  are  rinsed  in  the  same 
solution,  then  in  hot  water,  again  boiled 
in  the  soda  solution,  scrubbed  with  soap  and  water,  rinsed  in  hot  water, 
and  carefully  dried.  In  order  to  withstand  the  damaging  effects  of  this  treat- 
ment the  instruments  should  be  made  of  metal  throughout.     After  the  other 


Pig.  9. — Small  Steam-presscke  Sterilizer 
AND  Instrument  Boiler. 


Fig.   10. — Wringer  for  Hot  Towels,  Gauze,  Etc. 


instruments  have  been  boiled  the  edged  instruments  should  be  placed  in  the 
boiler  in  racks  (Fig.  6)  to  prevent  their  edges  from  becoming  dulled  by  coming 
in  contact  with  one  another,  and  boiled  for  two  minutes. 


THE   TREATMENT   OF   INFLAMMATION 


53 


The  Disinfection  of  Gowns,  Sheets,  Towels,  Gauze,  and  Dressing  Ma- 
terials.—This  is  best  acconiphshcd  by  exposure  to  flowing  steam,  or  steam 
\mder  ten  pounds  pressure  and  upward,  for  forty-five  minutes.  A  convenient 
apparatus  for  the  former  is  the  Arnold  steam  sterilizer  (Fig.  7).  In  order 
to  prevent  the  materials  from  becoming  wet  in  the  sterilizer  by  condensation 
of  the  steam  thereon,  they  should  be  first  warmed.  For  sterilizing  on  a  large 
scale  for  hospital  purposes  the  steam-pressure  apparatus  (Fig.  8)  is  to  be  used. 
A  convenient  coml)ination  of  steam-pressure  sterilizer  and  instrument  boiler 
for  office  use  is  shown  in  Fig.  9.  For  boiling  instruments  in  soda  solution 
and  sterilizing  gowns  and  dressing  materials  by  steam  at  the  same  time  the 


Fig.   11. — App\R«rs  for  Sterilizing  Catgut  by  Boiling  in  Alcohol. 

A,  fruit  jar  containing  jelly  jars  filled  with  catgut;  B,  Dowd's  condenser;  C,  water-bath;    D,  rubber 

corK  connecting  the  jar  with  the  condenser;  E,  tube  extending  from  body  of  condenser  through  wluch  the 

condensed  vapSr  of  the  alcohol  flows  back  into  the  jar;  F    tubing  connected  with  cold-water  faucet     O, 

outflow  tube  for  water  from  the  condenser;  H,  cotton-sealed  receptacle  for  overflow  of  alcohol,  1,  gas 


cork 


Sterilizer  of  S  c  h  i  m  m  e  1  b  u  s  c  h  is  convenient  and  efficient.  Squares  of 
gauze  to  be  used  in  place  of  flat  sponges  in  abdominal  section,  which  require 
to  be  warm  wdien  brought  in  contact  wdth  the  intestines,  may  be  iDoiled  in  a 
0.6  per  cent  solution  of  common  salt  (T  a  v  e  1)  and  kept  therein  until 
read^'  for  use,  when  they  are  wrung  out  (Fig.  10). 

The  Sterilization  of  Ligature  and  Suture  Material.— This  is  of  the  first 
importance.  Tn  spite  of  the  unfortunate  experiences  of  ^'  o  1  k  m  a  n  n  , 
who  observed  cases  of  anthrax  arising  from  infection  of  wounds  by  catgut, 
surgeons  are  loath  to  abandon  catgut  as  a  ligature  material.  It  may  be  boiled 
in  95  per  cent  alcohol  for  an  hour  without  impairing  its  strength,  as  I  have 


54 


INFLAMMATION 


heretofore  shown,*  and  h\boratory  experiments  made  for  me  by  Dr. 
H  o  d  e  n  p  y  1  prove  that  gut  thus  prepared  is  sterile  even  after  previous 
infection  with  anthrax.  Since  the  temperature  reached  by  boihng  alcohol 
(185°  F.)  can  scarcely  be  deemed  sufficient  to  effect  sterilization  alone,  particu- 


^^^^^^^^^^^^^^^^^ 

IH 

■ 

^^Mm 

|JH 

■ 

H 

P 

^fl 

ll 

ii 

Fig.   12. — Hermetically  Sealed  Bent  Glass 
Tube  Containing  Sterilized  Catgut. 


Fig.  13. — Breaking  the  Tube. 


larly  when  the  catgut  has  been  previously  infected  by  anthrax,  it  must  be 
assumed  that  in  the  method  of  boiling  in  alcohol  the  efficiency  of  the  steriliza- 
tion must  depend  to  a  great  extent  on  chemic  processes  occurring  in  connection 
with  the  heated  alcohol.  The  use  of  catgut  in  my  hands  has  been  followed 
by  the  most  satisfactory  results  in  cases  in  which  it  has  been  buried  in  the 
tissues.     It  should  never  be  used  as  a  skin  suture  for  the  reason  that  it  is 

almost  impossible  to  disinfect  the  skin  in  its 
depths,  and  the  catgut,  though  sterile,  passing 
through  this  structure  serves  as  a  pabulum  in 
the  presence  of  which  bacteria  already  pres- 
ent rapidly  proliferate  and  produce  irritation, 
and  at  times  infection.  An  apparatus  for  ster- 
ilizing catgut  by  boiling  in  alcohol,  which  has 
the  double  advantage  of  safety  and  economy 
of  alcohol,  as  originally  suggested  by  me,  has 
been  devised  by  Dr.  Dowd  (Fig.  11).  Cat- 
gut may  be  placed  in  bent  glass  tubes,  which 
are  filled  with  alcohol,  hermetically  sealed  and 
exposed  in  an  oven  to  a  temperature  of  185° 
F.  (the  boiling-point  of  alcohol)  for  an  hour 
(Fig.  12).  When  required  for  use,  the  tube  is 
simply  broken  (Fig.  13).  Fractional  steriliza- 
tion of  catgut  by  means  of  dry  heat  in  a  hot- 
air  sterilizer  (Fig.  8)  has  been  proposed.  Slowly 
heating  it  to  140°  C.  and  exposing  it  to  this 
temperature  for  three  hours  is  said  to  be  efficient  (R  ever  din,  Boeck- 
mann).  Another  method  consists  in  first  immersing  the  gut  in  ether  for 
*  New  York  Medical  Journal,  Aug.  16,  1890. 


Fig.  14. — Removing  the  Catgut. 


THE    TREATMENT    OF    IXFLAMMATIOX  00 

two  days  (B  r  a  t  z)  to  remove  the  fat,  and  then  in  a  1:500  sokition  of 
sublimate  in  alcohol  for  six  hours,  and  thence  transferring  it  to  pure  alcohol; 
or,  after  washing  in  ether  for  three  or  four  consecutive  days  it  may  be 
permanently  kept  in  a  1  :  500  ethereal  solution  of  sublimate  (S  c  h  a  p  p  s) . 
Alcohol  1000  parts,  glycerin  100  parts,  and  sublunate  1  part,  has  been  recom- 
mended as  a  preserA-ative  medium  (B  r  u  n  n  e  r).  If  stiff  gut  is  desired,  the 
glycerin  is  to  be  omitted  (Bergmann).  The  iodin  method  consists  in 
permanent  immersion  in  a  0.33  per  cent  solution  of  iodin  in  alcohol.  It  is 
immersed  one  Aveek  before  using.  Sterilization  by  means  of  combined  heat 
and  cumol  (Johns  Hopkins  Hospital)  requires  a  special  apparatus,  as  well  as 
some  handling  during  the  process.  Kangaroo  tendon  and  all  other  animal 
ligature  material  must  be  sterilized  in  the  same  manner  as  cat.gut.  Silk, 
silkworm-gut,  and  like  suture  material  may  be  conveniently  sterilized  by 
placing  them  in  the  steam  chamber  with  the  dressing  materials,  or  preferably 
by  boiling  them  for  five  minutes  in  a  0.6  per  cent  salt  solution  for  each  oper- 
ation (T  a  V  e  D . 

Dressing  of  the  Wound. — Except  for  the  purpose  of  washing  away  blood- 
clot,  irrigation  of  the  wound  will  not  be  required  in  aseptic  operations.  The 
wound  should  be  kept  as  dr\-  as  possible  (Landerer).  T^Tien  neces- 
sary-, a  solution  of  salt  in  sterilized  water,  one  dram  to  the  pint,  is  to  be  used. 
The  necessity  for  drainage  in  an  aseptic  wound  is  exceptional.  It  may  be 
required,  however,  where  there  are  large  dead  spaces  which  cannot  be  obliterated 
by  deep  sutures  or  by  the  pressure  of  the  dressings,  or  where  extensive  dissec- 
tion has  been  made.  Generally  speaking,  with  entire  arrest  of  hemorrhage  and 
careful  removal  of  all  blood-clot  an  aseptic  wound  may  be  closed  completely. 
The  dressing  of  an  aseptic  wound  consists  in  covering  it  vi'th  simple  sterile 
gauze  in  sufficient  quantities  to  protect  it  properly,  ai^plying  a  tliick  layer  of 
steam-sterilized  nonabsorbent  cotton,  and  securing  the  whole  in  place  by  a 
method  of  bandaging  adapted  to  the  part  operated  on.  As  rapid  evapor- 
ation of  wound  secretions  plays  an  important  part  in  preventing  putrefactive 
changes  in  aseptic  wounds,  impermeable  coverings  are  not  only  imnecessar}^ 
but  mischievous.  ^Miere  means  for  steam  sterilization  are  not  at  hand,  the 
gauze  may  be  boiled  in  the  0.6  per  cent  salt  solution  and  "^-nmg  out  as  dr\^ 
as  possible  before  being  applied,  large  Cjuantities  being  employed,  and  the  cot- 
ton omitted. 

"^Mien  it  is  necessary  to  pert'orm  the  operation  in  a  private  dwelling-house, 
additional  precautions  are  to  be  taken,  in  order  to  prevent  infection  from  the 
patient's  surroundings.  These  consist  in  clearing  all  furniture  from  the  room. 
removing  aU  hangings,  window  curtains,  etc.,  and  thoroughly  wetting  the  car- 
pet several  times  in  advance  with  a  1 :  1000  sublimate  solution.  Woodwork 
and  walls  are  to  be  washed  and  disinfected  -^ith  the  same  solution.  Perma- 
nent fixtures  are  to  be  covered  T^-ith  sheets  ^Ttmg  out  of  sublimate  solution. 
Doors  opening  into  closets  are  to  be  closed  and  sealed  by  plugging  the  cracks 
and  keyholes  with  cotton. 

A  reasonably  trustworthy  aseptic  immediate  emdronment  may  be  impro- 
\ased  in  private  dwelling-houses,  and  this  in  the  main  with  the  means  ordi- 
narily at  hand,  with  the  addition  of  a  supply  of  sublimate  tablets.  Freshly 
laundered  sheets  may  be  used  to  cover  a  well-scinibbed  domestic  table  to  be 
used  as  an  operating  table,  fixed  articles  of  furniture  or  those  too  hea^w  to  be 


56  INFLAMMATION 

removed  from  the  room,  and  the  patient  after  the  anesthetization  and  final 
preparation.  The  immediate  field  of  operation  may  be  surrounded  by  towels 
first  boiled  in  saline  solution  and  then  wrung  out  of  a  sublimate  solution. 
Washing  soda  from  the  household  supply  will  serve  to  make  the  solution  for 
boiling  the  instruments,  and  soap  from  the  laundry  will  answer  for  cleansing 
the  patient's  skin  and  the  hands  of  the  operator  and  his  assistants.  Gauze 
for  sponging  and  wound-dressing  purposes  may  be  sterilized  by  boiling  for  ten 
minutes  in  T  a  v  e  1 '  s  solution  made  with  sufficient  accuracy  by  dissolving  a 
teaspoonful  of  table  salt  in  a  pint  of  Avater.  Clean  sheets  arranged  in  Roman 
toga  fashion  may  be  substituted  for  operating  gowns.  Utensils  selected 
from  the  kitchen  outfit  for  boiling  the  instruments  and  gauze,  a  fire  in  the 
kitchen  stove,  and  a  plentiful  sujoply  of  boiled  water  will  serve  for  the  rest. 

The  Antiseptic  Treatment  of  Wounds. — Every  Avound  that  has  been 
exposed  to  infection  must  be  treated  antiscptically.  Wounds  already  infected 
must  be  protected  against  infection  by  an  antiseptic  regimen.  In  accident- 
ally inflicted  wounds  the  parts  must  be  cleansed,  foreign  bodies  removed,  and 
bruised  tissue  likely  to  die  cut  away.  The  surroundings  are  to  be  shaved, 
scrubbed,  and  disinfected  precisely  as  if  no  infection  had  taken  place.  The 
wound  itself  is  to  be  irrigated  with  a  1 :  2000  sublimate  solution  and  closed, 
drainage  being  provided  for.  An  alcohol  sublimate  solution  consisting  of  mer- 
curic chlorid,  1  part,  and  50  per  cent  alcohol,  2000  parts,  may  be  used  with 
advantage  at  the  first  two  or  three  dressings  in  suppurating  wounds,  the  cavity 
of  the  wound  being  packed  with  gauze  wrung  out  of  this  solution. 

Drainage. — This  may  be  provided  for  (1)  by  leaving  the  entire  wound, 
or  at  least  the  most  dependent  part  thereof,  open;  (2)  by  enlarging  wounds 
too  small  to  permit  of  drainage  (compound  fractures) ;  (3)  by  making  counter- 
openings  at  proper  points;  (4)  b}''  securing  primary  drainage  and  secondary 
suture,  i.  e.,  placing  sutures  in  position,  leaving  the  wound  open,  and  packing 
it  with  iodoform  or  other  antiseptic  gauze,  and  in  the  course  of  twenty-four 
or  forty-eight  hours  drawing  its  edges  together  with  the  sutures  already 
placed  (K  o  c  h  e  r) ;  (5)  by  using  drains,  either  capillary  or  tube.  Capil- 
lary drains,  consisting  of  wicking,  plain  or  wrapped  in  gauze,  perforated  oiled 
silk,  or  rubber  tissue,  or  narrow  strips  of  gauze,  will  conduct  away  serum  if 
the  wound  is  a  recent  one.  Narrow  strips  of  oiled  silk  or  rubber  tissue  will -also 
be  of  service,  under  the  same  circumstances.  For  tube  drainage  fenestrated 
rubber  or  annealed  glass  is  generally  used.  When  extra  rigidity  of  the  walls 
of  a  rubber  drainage-tube  is  required,  the  latter  may  be  immersed  for  five 
minutes  or  more,  according  to  the  size,  in  commercial  sulfuric  acid  (Ja- 
varro).  In  order  to  avoid  the  necessity  for  the  removal  of  tube  drains  it 
has  been  proposed  to  employ  those  made  of  bone  and  subsequently  decalcified 
(N  e  u  b  e  r)  or  those  of  the  long  hollow  bones  of  fowls  (Mace  wen, Tren- 
delenburg). Tube  drains  should  be  prevented  from  slipping  too  far 
into  the  Avound  by  a  safet\'-pin  placed  across  them  at  their  point  of  exit.  What- 
ever material  is  employed  for  facilitating  drainage  from  a  AAOund  should  be 
removed  and  dispensed  with  as  soon  as  possible.  Its  presence  exerts  an  irri- 
tating influence  and  excites  secretion  from  the  wound  surfaces.  All  drains 
before  being  introduced  into  the  wound  should  be  sterilized  by  boiling. 

Antiseptic  Dressing. — The  antiseptic  dressing  of  a  wound  demands  that 
absorbent  material  impregnated  with  an  antiseptic  agent,  and  hence  capable 


THE    TREATMENT    OF    INFLAMMATION  57 

of  (lisinfectins^  septic  discharges,  be  a])j)licd.  Sterilized  p:;anze  wrung  out  of 
sublimate  solution  \vill  answer  in  many  cases.  b)doform  gauze  treated  in  the 
same  manner  is  ^•ery  useful.  Where  dermatitis  results  from  contact  of  sub- 
limate or  iodoform,  and  where  the  toxic  properties  of  the  latter  are  to  be  feared, 
gauze  wrung  out  of  a  mixture  of  oxid  of  zinc  in  sterilized  water  is  to  be  substi- 
tuted. In  chronic  suppurating  cases  (ischiorectal  abscesses,  etc.)  iodoform 
gauze  wrung  out  of  alcohol  is  very  efficient.  Disarrangement  of  the  dressings 
b}''  the  restlessness  of  the  patient  should  he  provided  against  by  the  applica- 
tion of  proper  splints,  adhesive  plaster,  starched  crinoline,  or  plaster-of-Paris 
bandages,  in  addition  to  the  ordinary  bandages.  These  ser\-e  also  as  impor- 
tant additional  means  of  securing  prompt  healing  in  parts  otherwise  freely 
movable,,  by  insuring  rest.  Moderate  compression  to  overcome  muscular  spasm 
is  useful  in  all  dressings,  and  the  influence  of  position  in  securing  comfort  and 
facilitating  drainage  is  to  be  borne  in  mind. 

The  indications  for  redressing  a  wound,  exclusive  of  those  which  arise 
from  accidental  displacement  or  soiling  from  without,  are  as  follows:  (1)  the 
occurrence  of  pain  due  to  tension  from  sw^elling  or  accumulation  of  wound  secre- 
tions ;  (2)  the  appearance  of  discharge  on  the  surface  or  at  the  edges  of  the  dress- 
ings ;  (8)  the  necessity  for  removal  of  the  drain ;  (4)  the  removal  of  the  sutures ; 
(5)  the  rise  of  temperature  after  the  first  twenty-four  hours,  showing  the  occur- 
rence of  systemic  infection  from  the  \vound  as  a  septic  focus.  In  order  to  recog- 
nize promptly  the  last-named  indication  the  temperature  should  be  taken 
every  four  hours  during  the  first  few  da3^s.  On  removing  the  dressings  the 
condition  of  the  wound  and  surrounding  parts  must  be  carefully  investigated. 
Tension  on  sutures  is  to  be  relieved  by  removal  of  one  or  more  of  these. 
Pent-up  discharges  are  to  be  furnished  exit  by  separating  the  wound  edges. 
Slough  or  clots  are  to  be  removed  by  the  curet.  Inflamed  or  phlegmonous 
conditions  in  the  neighborhood  are  to  be  relieved  by  reopening  the  wound, 
and  by  incisions  in  addition,  and  they,  as  well  as  the  original  wound,  are  to  be 
treated  by  sublimate  irrigation  and  tamponed  with  iodoform  gauze  A^Tung 
out  of  alcohol  or  w-et  sublimate  gauze.  Compresses  of  the  latter  are  to  be 
applied  as  dressings,  and  daily  or  twice  daily  reappli cations  of  these  practised 
until  the  symptoms  disappear.  When  a  simple  serous  or  serosanguinolent 
discharge  appears  and  no  other  symptoms  are  present  indicating  removal  of 
the  dressings,  this,  if  it  dries  rapidly,  may  be  covered  by  another  sterile  or 
antiseptic  dressing.  The  drainage-tube  may  be  removed  on  the  third  day, 
unless  some  positive  indication  for  its  further  use  exists.  If  there  is  any  doubt 
as  to  this,  it  may  be  shortened  at  each  dressing. 

The  occurrence  of  stitch  abscesses  in  skin  A^hich  has  been  cleansed  with 
the  most  scrupulous  (^are  is  to  be  attributed  to  the  presence  of  Staphylococcus 
epidermidis  albus  of  W  e  1  c  h  .  This  observer  found  that  after  sterihzation 
of  the  surface  the  presence  of  this  coccus  could  still  be  demonstrated  by  making 
cultures  from  sutures  passed  through  the  skin,  or  from  excised  portions  of  the 
skin.  While  ordinarily  innocuous,  under  the  influence  of  lessened  local  vital 
resistance,  such,  for  instance,  as  the  strangulation  of  tissues  and  the  resulting 
necrosis  from  the  pressure  of  a  stitch-loop,  or  the  presence  of  foreign  bodies 
in  the  wound,  it  may  become  the  cause  of  disturbance  manifested  by  local- 
ized suppuration  and  elevation  of  temperature.  No  time  should  be  lost  in 
relieving  the  pressure ;  the  sutures  should  be  removed  and  the  infected  tissues 


58 


INFLAMMATION 


through  which  they  pass  curetted  to  remove  all  necrotic  tissue,  with  a  sinus 
curet  (Fig.  15).  Each  suture  track  should  then  be  disinfected  and  packed  with 
antiseptic  gauze. 

The  time  for  the  removal  of  the  sutures  will  depend  on  the  exigencies 
of  the  case.  They  should  not  be  permitted  to  bury  themselves  in  the  skin, 
except  under  exceptional  conditions.  Where  no  tendency  of  the  wound  edges 
to  gape  is  present,  they  may  be  removed  early.  On  the  contrary,  wounds 
involving  the  abdominal  wall  will  require  a  longer  support. 

Under  circumstances  in  which  it  has  been  necessary  to  remove  sutures  on 

account  of   septic    conditions,  as  well  as  when  it  has  been  necessary  to  omit 

these  from  the  commencement,  with  the  subsidence  of  the  local  inflanmiation 

and  in  the  presence  of  healthy  granulations,  attempts  to  close  the  wound  and 

hasten  the  healing  process  may  be  made  by  the  use  of  either 

adhesive  plaster  strapping    or    secondary    sutures.      Care 

should  be  taken  to  pre^'ent  rolling  in  of  the  skin  edges. 

Finally,  in  summing  up  the  indications  for  redressing  a 
wound  emphasis  is  to  be  placed  on  the  dictum  that,  in 
doubtful  cases,  it  is  better  to  dress  the  wound  once  too  often 
than  once  too  seldom,  and  then  perhaps  too  late.  On  the 
other  hand,  the  general  principles  of  c^uiet  and  infrequent 
dressings  are  to  be  borne  in  mind.  While  a  careful  watch 
should  be  kept  for  indications  for  removing  the  dressings, 
meddlesome  and  unnecessary  interference  does  harm.  The 
act  of  dressing  should  be  carefully  performed  and  all  precau- 
tions taken  to  prevent  further  infection.  Too  much  sponging 
and  Aviping  and  even  forcible  irrigation  is  mischievous. 
"WTiatever  causes  bleeding  from  the  wound  is  to  be  avoided. 
Losses  of  substance  or  severely  contused  conditions  of  the 
w^ound  may  lead  to  failure  to  approximate  the  wound 
edges.  It  should  be  tightly  packed  after  being  cleansed,  if 
sepsis  is  suspected,  or  covered  A\'ith  simple  sterile  dressing  if 
not.  If  an  antiseptic  condition  is  maintained,  granulations 
gradually  fill  up  the  space.  The  discharge  consists  of  plasma 
and  a  few  migrating  cells  or  leukocytes.  The  completion 
of  the  healing  process  is  marked  by  the  formation  of  a  skin 
covering  from  the  rete  Malpighii  at  the  margins. 
The  occurrence  of  profuse  granulations  is  to  be  met,  if  these  are  florid 
and  due  to  the  too  rapid  development  of  vessels,  by  the  application  of  caustic 
substances,  such  as  the  nitrate  of  silver,  or  by  removal  by  knife  or  scissors.  If 
pale  and  flabby  from  an  edematous  condition,  and  particularly  if  a  tubercu- 
lous infection  is  present,  they  must  be  curetted  away,  and  stimulating  and 
antituberculous  remedies,  such  as  combinations  of  naphthalin  and  iodoform, 
or  Peruvian  balsam,  applied. 

In  foul-smelling  wounds  with  grayish,  sloughy-looking  surfaces  the 
curet  should  be  vigorously  used,  followed  by  the  application  of  a  10  per  cent 
solution  of  chlorid  of  zinc.  This  should  be  well  rvibbed  in  and  foUo^Aed  by 
packing  mth  a  stimulating  antiseptic  gauze  (gauze  treated  AA'ith  naphthalin 
and  Peruvian  balsam).  The  process  of  curetting  and  "scouring'"  should  be 
repeated,  if  necessary,  at  subsequent  dressings. 


Fig.  15. 

Delatour's  Sinus 

Curet. 


THE    TREATMENT    OF   INFLAMMATION 


59 


7- 


lf\1 


^ 


One  of  the  sequels  of  an  infected  wound  is  an  opening  or  sinus  leading  from 
the  surface  to  a  suppurating  cavity. 

The  infected  area  is  to  be  thoroughly  curetted  with  the  sinus  curet 
(Fig.  15)  and  treated  by  stimulating  and  bactericidal  agents,  injected  into 
its  depths  and  incorporated  in  gauze  and  carried  to  the  bottom  of  the  sinus. 
Chlorid  of  zinc,  followed  by  hydrogen  peroxid,  the  latter  principally  for  its 
mechanical  cleansing  properties,  and,  after  irrigation,  the  introduction  of 
Peruvian  balsam  incorporated  in  gauze  fulfil  the  indications,  as  a  rule.  A 
persistently  discharging  sinus  may  be  due  either  to  the  presence  of  necrosed 
bone  or  other  foreign  body  or  to  septic  conditions  involving 
the  walls.  The  former  should  be  searched  for  and  removed ; 
the  latter  should  be  met  first  by  thorough  curetting  followed 
by  injection  of  the  sinus  with  a  95  per  cent  solution  of  car- 
bolic acid  by  means  of  a  sinus  syringe  (Fig.  16).  After  the 
lapse  of  from  one  to  two  minutes  the  carbolic  acid  is  dissolved 
and  washed  away  with  alcohol  and  the  opening  dressed  with 
sterile  gauze  without  drainage.  Or,  equal  parts  of  carbolic 
acid  and  tincture  of  iodin  may  be  injected  and  the  parts 
dressed  at  once  with  sterile  gauze. 

Antiseptic  Agents. — Antibacterial  or  antiseptic  agents 
are  those  drugs  and  appliances  which  either  possess  a  de- 
structive (disinfectant,  sterilizing)  power  or  exert  an  inhibitory 
influence  in  their  relation  to  microorganisms.  Of  the  first 
of  these,  the  most  powerful  is  heat.  This  is  applicable  only 
to  instmments,  dressing  materials,  etc. 

Corrosive  Sublimate  (Mercuric  Chlorid). — This  bac- 
tericidal agent  is  most  generally  applicable  to  the  require- 
ments of  antisepsis  in  its  relation  to  the  body.  The  demon- 
stration of  its  bactericidal  properties  (K  o  c  h)  was  soon 
followed  by  its  introduction  into  surgical  practice  (S  c  h  e  d  e  ; 
Bergmann,  1878),  and  it  almost  completely  replaced 
carbolic  acid,  which  under  the  influence  of  Lister's 
teaching  was  theretofore  the  most  universally  employed  an- 
tiseptic. It  is  usually  emplo3^ed  in  solutions  of  from 
1:1000  to  1 : 5000,  though  the  weakest  of  these  is  irritating 
to  the  tissues  in  some  situations  (the  eye  and  urethra). 
In  joint  cavities  a  1:5000  solution  is  employed.  The  vaginal 
canal  may  be  irrigated  with  a  1 :  3000  solution,  and  the  uterine 
cavity  as  well,  if  proper  provision  for  the  return  flow  is  made 
beforehand  by  thorough  dilatation  of  the  cervix.  A  solution 
not  stronger  than  1 : 20,000  is  to  be  employed  in  the  urethra  in  the  beginning;  as 
the  sensitiveness  lessens  under  frequent  use  and  instrumentation,  the  strength 
may  be  increased.  A  sublimate  solution  is  never  to  be  employed  in  the  mouth 
or  rectmn  for  irrigating  purposes  on  account  of  its  toxic  properties ;  abdominal 
pain,  tenesmus  with  bloody  mucous  stools,  etc.,  follow.  These  symptoms  may 
also  occasionally  follow  absorption  from  wound  surfaces,  though  they  are  rarely 
of  so  pronoimced  a  character.  Such  disagreeable  symptoms  as  eczema,  saliva- 
tion, and  stomatitis  may  occur  in  sensitive  individuals.  These,  as  weH  as  the 
slight  superficial  necrosis  which  follows  contact  of  the  tissues  ^dth  the  stronger 


(It 


Fig. 


16.— Si  nus 
Syringe. 


60  INFLAMMATION 

solutions,  may  be  prevented  to  a  considerable  extent  b}'  washing  the  latter  a\\'ay 
subsequently  with  the  sterilized  normal  salt  solution.  The  presence  of  alka- 
line earths  in  common  water  interferes  somewhat  with  the  solubility  of  corro- 
sive sublimate,  and  for  this  reason  the  addition  of  some  acid,  such  as  tartaric, 
citric,  or  acetic  acid,  is  useful.  Ammonium  chlorid  (sal  ammoniac)  or  sodhim 
chlorid  (common  cooking  salt)  will  act  as  correctives  in  effecting  the  solution. 
In  the  case  of  any  of  these  agents  the  amount  employed  should  equal  that  of 
the  mercuric  chlorid.  The  beneficial  results  following  the  use  of  mercuric 
chlorid  as  a  local  application  to  infected  wounds  are  greatly  enhanced  by  the 
addition  of  alcohol  to  the  solution  (corrosive  sublimate,  1  part,  alcohol  and 
water,  of  each  1000  parts).  Experimental  research  confirms  the  results  of 
clinical  experience  as  to  the  value  of  mercuric  chlorid  and  the  other  bactericidal 
agents  in  antiseptic  wound  treatment  (H  e  n  1  e).  Its  availability,  cheapness, 
and  undoubted  disinfectant  properties  have  combined  to  render  it  the  most 
popular  agent  of  its  class. 

Mercuric  lodid. — This  is  a  trustworthy  antiseptic  of  the  bactericidal 
closs,  and  is  used  more  especially  in  operations  on  the  eye.  Its  effects  on 
polished  instnunents  are  not  so  pronounced  as  those  of  corrosive  sublimate. 
It  is  used  in  strengths  varying  from  1 :  4000  to  1 :  12,000.  Its  solubility  in  water 
should  be  aided  by  the  addition  of  an  equal  portion  of  potassium  iodid.  The 
expense  of  its  manufacture  as  compared  with  the  expense  of  mercuric  chlorid 
has  been  a  bar  to  its  universal  employment. 

Carbolic  Acid. — This  is  one  of  the  inhibitory  antiseptic  agents,  and  is  em- 
ployed in  the  strength  of  from  2.5  to  5  per  cent.  It  possesses  the  property 
of  decidedly  penetrating  the  skin  surface  (Hueter),  and  for  this  reason, 
in  connection  vdth  opium  and  sufficient  glycerin  to  assure  the  solubility  of 
the  carbolic  acid,  is  a  useful  application  in  inflammatory  conditions  of  the  sur- 
face, replacing  the  lead  and  opium  wash  of  the  older  surgeons.  To  each  pint 
of  a  2.5  per  cent  solution  one  ounce  of  tincture  of  opium  is  added.  It  should 
be  used  with  caution  in  young  children  and  old  persons.  Its  toxic  properties 
are  first  manifested  in  connection  with  the  kidneys,  the  urine  becoming  a  dark 
olive-green  or  black.  Nausea,  vomiting,  and  a  rapid  and  small  pulse  are  the 
other  symptoms,  followed  by  coma  and  death.  Carbolic  acid  may  be  found  in 
the  urine.  It  should  not  be  used  in  cases  in  which  chronic  degenerative  diseases 
of  the  kidneys  exist.  It  is  absorbed  through  both  the  lymph- channels  and  the 
blood-vessels;  in  the  case  of  the  skin  it  passes  through  the  thin  epidermis  and 
into  the  vessels,  hence  its  value  in  septic  dermatitis  and  cellulitis.  This  also 
explains  the  fact  that  young  children  with  very  delicate  epithelial  covering, 
and  old  persons  with  atrophic  skin  are  specially  susceptible  to  its  influence 
when  it  is  used  in  this  manner.  The  treatment  of  carbolic  acid  poisoning 
consists  in  suspending  the  use  of  the  drug,  stimulating  with  alcohol  and 
camphor,  the  administration  of  10-  to  2d-gram  doses  of  sulfate  of  soda 
(S  o  n  n  e  n  b  u  r  g)  if  the  urine  remains  dark  colored,  and  the  application  of 
drv'  cups  in  the  renal  region  and  intravenous  saline  infusion  if  suppression 
is  threatened.  Local  troublesome  eczema  may  follow  its  prolonged  use  as  a 
wound  dressing. 

Zinc  Chlorid. — This  is  a  very  useful  antiseptic,  and  Avas  emijlo3'ed  as 
early  as  1866  (Campbell  de  Morgan)  after  operations  for  carci- 
noma.    Later  it  was  employed  in  the  primar}^  treatment  of  compound  frac- 


THIO    TREATMENT    OF    INFLAMMATION  61 

ture  (L  i  s  t  c  r  ,  ^'  o  1  k  m  a  ii  n),  and  as  a  })crmanent  wound  dressing  (zinc 
chlorid  lint  and  jute,  1^  a  r  d  e  1  e  b  e  n).  It  may  be  used  in  extremely 
septic  Moiuids  of  long  standing  in  a  10  per  cent  solution.  In  those  in  which 
less  energetic  measures  are  required,  a  5  per  cent  solution  will  suffice.  As  a 
pernianont  dressing  it  is  irritating  to  the  skin. 

Salicylic  Acid. — This  is  one  of  the  syntlictically  produced  antiseptics. 
It  is  used  in  strengths  of  from  1  :oO()  to  1 :  100;  its  solution  in  water  is  aided  by 
the  addition  of  six  times  its  weight  of  boric  acid  (Thiersch  :  sali- 
cylic acid  15,  boric  acid  90,  water  500).  It  is  nonpoisonous  in  these  strengths, 
and  is  employed  for  irrigating  purposes  where  sublimate  solutions  are  unsafe. 
It  is  a  useful  application  to  the  skin  in  preparing  the  latter  for  operation, 
because  of  the  property  which  it  possesses  of  separating  dead  epithelial  scales 
from  tlie  surface. 

Iodoform. — The  antiseptic  properties  of  tliis  agent  are  developed  by  the 
liberation  of  free  iodin  in  the  presence  of  the  products  of  bacterial  decomposi- 
tion (ptomains  and  toxalbumins) .  When  employed  in  cases  in  which  sujopura- 
tion  is  not  present  it  should  be  sterilized  before  being  used.  It  is  said  to  possess 
hemostatic  properties.  It  is  used  principally  in  tuberculous  disease,  and  as  a 
mild  inhibitor}^  agent  to  the  growth  of  pyogenic  organisms.  A  10  per  cent 
emulsion  of  iodoform  in  glycerin  is  used  as  an  intraarticular  and  parenchyma- 
tous injection  in  tuberculous  affections  of  bones  and  joints.  It  is  slow  in  its 
action,  owing  to  its  insolubility.  Its  principal  use  is  in  the  shape  of  iodoform 
gauze  for  tamponing  cavities  in  the  neighboi'hood  of  the  rectum  and  -v'agina, 
particularly  when  free  oozing  of  blood  occurs  from  these,  and  as  an  antituber- 
culous  application  to  the  ^^■ound  surfaces  after  resection  and  erasion  of  tuber- 
culous joints.  Iodoform  gauze  is  sometimes  used  to  wall  off  septic  intraperi- 
toneal areas  from  the  remainder  of  the  cavity  of  the  abdomen,  as  in  suppurative 
appendicitis.  The  toxic  properties  of  iodoform  are  pronounced  and  the  symp- 
toms of  poisoning  are  of  both  a  general  and  a  local  character.  The  former 
are  the  more  important,  and  consist  of  headache,  nausea,  and  vomiting;  in  more 
serious  cases  increased  frecjuency  of  the  pulse,  rise  of  temperature,  confusion 
of  ideas,  delirium,  coma,  and  death  follow.  The  symptoms  and  postmortem 
appearance  resemble  those  of  acute  meningitis.  Old  persons  and  young  chil- 
dren are  peculiarly  susceptible  to  its  toxic  influences.  Withdrawal  of  the  drug 
will  usually  arrest  the  early  symptoms.  The  same  general  measures  of  treat- 
ment as  in  carbolic  acid  poisoning  are  used.  The  use  of  sodium  chlorid  in  large 
quantities  has  been  suggested  as  an  antidote.  Intravenous  saline  infusion 
should  be  emplo^'ed. 

Acetate  of  aluminum,  a  nonpoisonous  agent,  Is  used  as  an  astringent  and 
mild  antiseptic  solution  in  certain  phlegmonous  affections  requiring  perma- 
nent immersion  and  irrigation.  It  is  used  in  from  1  to  3  per  cent  solu- 
tions (B  ii  r  o  w).  The  following  formula  affords  a  ready  means  of  making  a 
1  per  cent  B  ii  r  o  w  '  s  solution : 

Alumen 5  parts 

Plumbi  acetas 25  parts 

Aqua 500  parts 

Creolin  is  used  in  the  shape  of  a  milky  mixture  with  water  in  the  propor- 
tion of  from  one  to  two  parts  in  a  hundred,  as  a  substitute  for  carbolic  acid. 


62  IXFLAMMATIOX 

It  is  said  to  be  nonpoisonous.  Lysol  belongs  to  the  same  class  of  coal-tar 
products  as  the  last  named,  and  is  used  in  a  similar  manner.  Thymol  is 
ver}-  insoluble,  and  does  not  find  a  wide  range  of  usefulness.  In  the  proportion 
of  i :  1000  it  is  an  agreeable  addition  to  certain  mouth-washes.  It  is  nontoxic. 
Boric  acid  is  the  most  frequently  employed  of  the  weak  antiseptics.  It 
is  used  principally  for  irrigating  the  bladder,  cavity  of  the  mouth,  and  rectum, 
and  as  an  addition  to  solutions  of  salicylic  acid  (Thiersch's  solu- 
tion).    It  is  also  extensively  employed  in  the  shape  of  boric  acid  ointment. 

In  addition  to  the  above,  C[uite  a  large  number  of  more  or  less  useful  anti- 
septic agents  have  been  introduced,  which  may  prove  useful  under  special 
circumstances.  Among  these  may  be  mentioned  naphthalin,  subnitrate 
of  bismuth,  oxid  of  zinc,  hydronaphthol,  aristol,  dermatol,  and  subiodid 
of  bismuth.  Besides  these,  there  are  some  which  are  supposed  to  exert  a 
specific  effect  on  the  bacillus  of  tuberculosis,  such  as  Peruvian  balsam  and 
cinnamic  acid. 

The  Selection  of  an  Antiseptic. — No  hard  and  fast  rule  can  be  laid  do-^ai 
for  the  selection  of  an  antiseptic  for  any  particular  case.  It  is  far  more  impor- 
tant that  the  surgeon  should  be  familiar  with  the  uses  of  a  few  antiseptics  than 
that  he  should  attempt  to  limit  with  sharply  defined  lines  the  special  uses  of 
a  large  number.  For  the  purpose  of  aseptic  irrigation  ordinary  sterilized 
saline  solution  (0.6  per  cent  solution  of  sodium  chlorid)  is  all  that  is  needed. 
Solutions  in  varying  strengths  of  sublimate,  carbolic  acid,  zinc  chlorid, 
salicylic  acid,  or  boric  acid  are  used  in  suppurating  wounds  and  cavities. 
Iodoform  is  most  advantageously  employed  in  tuberculous  cases,  and 
Peruvian  balsam  and  naphthalin  in  indolent  granulating  surfaces  and 
sinuses.  As  for  the  rest,  they  are  more  or  less  useful  when  incorporated  in 
hygroscopic  cheese-cloth  or  gauze.  Oxid  of  zinc  and  boric  acid,  alone  or 
combined,  are  useful  dusting-powders. 

Antiseptic  Ointments. — These  are  but  ver\'  little  used  at  the  present 
day,  except  where  sensitive  areas  about  a  wound  are  to  be  protected  against 
irritating  wound  discharges  or  contact  with  antiseptic  substances.  Vaselin  one 
part  and  paraffin  two  parts  form  the  best  base  for  an  ointment.  Salicylic 
ointment  is  made  by  adding  one  part  of  sahcylic  acid  to  twenty-nine  parts 
of  the  above  base.  Boric  acid  ointment  is  made  by  adding  one  part  of  the 
acid  to  ten  parts  of  the  same  base.  Salicylic  cream  is  made  by  mixing  one 
part  of  the  acid  to  ten  parts  of  glycerin.  Carbolized  oil  in  varying  strengths 
(1:5;  1:10;  1:20)  is  likewise  employed  for  the  purpose  mentioned,  as  well  as 
for  oiling  the  examining  finger  and  instruments. 

Dressing  Materials.— Cheese-cloth,  butter-cloth,  or  absorbent  gauze, 
introduced  by  Lister,  is  the  standard  dressing  material.  Any  of  the 
antiseptic  substances  may  be  incorporated  in  this.  Except  in  cases  of  special 
susceptibility,  the  most  generally  useful  antiseptic  dressing  material  is  gauze 
wrung  out  of  a  corrosive  subhmate  solution.  In  strictly  aseptic  operations 
steam-sterilized  plain  gauze  suffices.  The  antiseptic  gauzes  furnished  by 
the  manvcfacturers  should  undergo  a  further  process  of  sterilization  in  the 
steam  sterilizer  before  being  used.  The  sterilization  of  the  manufacturer  is  not 
to  be  trusted;  sufficient  time  usually  elapses  between  the  sterilization  and  the 
final  use  to  permit  reinfection.  When  practicable,  heat  should  be  used  for  the 
sterilization. 


THE   TREATMENT   OF   INFLAMMATION  63 

Iodoform  gauze  cannot  be  sterilized  by  heat  owing  to  the  decomposition  of 

the  iodoform.  It  should  l>o  A\runo-  out  of  sublimate  solution  before  being 
used.  Peruvian  balsam  gauze  is  a  useful  means  of  conveying  this  medica- 
ment into  sinuses,  etc.  Should  a  still  greater  stimulating  effect  be  desired, 
naphthalin  may  be  added  to  the  balsam  in  the  proportion  of  one  dram 
to  the  ounce.  The  gauze  is  simply  saturated  with  the  balsam  and  the 
superfluous  portion  pressed  out.  It  should  be  heat-sterilized  before  being 
used.  In  addition  to  gauze  dressing  materials,  which  are  relatively  expen- 
sive, cheaper  dressings  have  been  devised  to  serve  in  making  up  the  bulk 
of  large  dressings.  These  consist  of  absorbent  cotton  (B  r  u  n  s ) ;  jute 
(Mos'engeil);  peat  moss  (Leisrink);  peat  (Neuber);  forest 
moss  (H  a  g  e  d  o  r  n) ;  sawdust  (P  i  1  c  h  e  r) ;  wood-wool  and  paper- 
wool  (Fowler).  These  are  made  into  cushions,  and  may  be  impreg- 
nated with  antiseptic  substances,  but  should  be  heat-sterilized  before  being 
used.  Cotton  batting  furnishes  a  cheap  and  useful  means  for  protecting 
dressings  after  they  have  been  placed  in  position.  In  addition,  it  assists  in  the 
even  distribution  of  pressure  as  applied  by  retentive  bandages.  It  should  be 
nonabsorbent  for  the  reason  that  in  this  condition  it  is  a  more  effectual  bar- 
rier against  microbic  invasion,  and  it  is  to  be  heat-sterilized. 

The  method  of  applying  gauze  dressings  is  as  foUo^vs:  A  yard  square  of 
the  material  is  applied  in  a  cnmipled  mass  to  the  wound.  This  is  repeated 
until  several  layers  are  placed  in  position,  or  the  cushions  of  paper-wool  may 
follow.  Over  the  entire  mass,  particularly  at  the  edges,  is  superimposed  a 
thick  layer  of  sterilized  cotton  wadding,  the  whole  is  secured  in  place  ^\-ith 
turns  of  a  roller  bandage,  the  latter  preferably  of  gauze  also. 

Superficial  wounds  of  the  face  may  be  treated  without  any  dressing  other 
than  the  apphcation  of  collodion  mixed  vdth  iodoform,  subnitrate  of  bismuth, 
oxid  of  zinc,  or  boric  acid  or  salicylic  acid.  Any  of  these  latter  may  be 
applied  as  a  poAvder  dressing  to  superficial  granulating  surfaces  or  excoriations. 

Local  Antiphlogistic  Measures.—There  are  certain  local  measures  which, 
while  in  one  sense  acting  to  arrest  septic  symptoms,  yet  cannot  be  said  to  be 
directed  against  the  cause  of  the  inflammation  in  the  sense  of  antisepsis. 
These  symptomatic  remedies  are  directed  toward  the  arrest  of  spreading 
dermatitis  and  lymphangitis  occurring  in  the  neighborhood  of  infected  wounds, 
which  are  not  arrested  by  the  remedies  used  in  the  wound  itself  or  its  im- 
mediate neighborhood.  These  consist  of  certain  ointments  and  moist  applica- 
tions. Zinc  oxid  ointment  is  most  commonly  employed.  The  ordinary 
mercurial  ointment  is  sometimes  used  for  this  purpose.  A  10  per  cent  mix- 
ture of  ichthyol  with  lanolin  is  another  useful  remedy. 

The  local  use  of  ice  is  founded  on  rational  therapeutic  principles.  It 
abstracts  heat  and  locally  diminishes  the  quantity  of  blood  by  contracting  the 
vessels.  It  tends  also  to  arrest  the  development  of  bacteria  and  lessens  the 
pain,  or  abates  it  entirely.  Its  use,  however,  is  restricted  to  ca.ses  in  which 
large  dressings  are  not  employed,  as,  for  instance,  inflamed  joints.  Here 
also  its  use  islimited.  In  joints  in  which  the  capsule  is  superficial,  such  as  the 
knee-joint,  it  is  of  great  advantage,  vrhile  in  the  hip-joint  it  is  entirely  useless. 
The  local  abstraction  of  blood  hi  inflamed  areas,  formerly  so  much  in  vogue,  is 
now  substituted  by  position,  particularly  in  the  case  of  the  extremities ;  elevation 
of  the  inflamed  parts  answers  all   the   requirements  of  local  blood-letting. 


64  INFLAMMATION 

So-called  derivatives  or  measures  of  counter-irritation  are  used  less  fre- 
quently than  in  former  times.  Blistering  and  cauterization  are  still  believed 
by  many  surgeons  to  be  of  service  in  chronically  inflamed  joints,  particularly 
the  knee-joint,  when  combined  with  fixation. 

Tenosynovitis  and  chronic  inflammatory  conditions  else^vhere  are  ad- 
vantageously treated  by  massage.  This  consists  of  massage  a  friction 
(simple  friction  movements  with  the  finger-tips),  eflEieurage  (rubbing  with  an 
ointment),  petrissage  (kneading  with  both  hands  at  right  angles  with  the 
long  axis  of  the  parts),  and  tapotement  (beating  the  soft  parts  ^\-ith  the  ulnar 
margin  of  the  hands  or  the  closed  fist).  ]\Iassage  is  particularl}-  useful  in  old 
cases  of  serous  or  serofibrinous  inflammation  and  in  cases  of  edematous  swelhng 
and  infiltration  following  such  injuries  as  severe  sprains,  fractures,  and  dis- 
locations, and  after  the  subsidence  of  suppurative  inflammation.  It  is  con- 
traindicated  in  acute  inflammation,  particularly  where  this  disposes  toward 
suppuration.  It  should  not  be  employed  in  specific  or  granular  inflammatory 
conditions,  lest  f\irther  disseminations  and  propagation  of  pathologic  ele- 
ments be  favored  by  forcing  these  into  neighboring  lymph-channels.  Steadily 
maintained  equable  pressure  favors  lymphatic  resorption.  The  roller  band- 
age is  a  most  useful  antiphlogistic  measure.  The  elastic  bandage  of  Martin 
or  the  material  known  as  "stockinet"  is  a  valuable  means  of  accomplishing 
this  pressure.  Care  is  necessary  in  the  application.  The  ease  with  which  a 
very  slight  pressure  will  serve  the  purpose  is  quite  surprising.  Onh^  just 
enough  pressure  to  hold  the  bandage  in  place  is  usually  sufficient  when  the 
rubber  bandage  is  employed.  Elastic  compression  is  employed  with  advan- 
tage as  an  adjunct  method  of  treatment  to  massage.  Warm  baths  are  like- 
wise useful  in  the  treatment  of  old  inflammatory  residua.  These  may  be 
simply  of  v^ater  of  normal  temperature,  or  certain  medicaments  and  salts 
may  be  added  to  aid  resorption.  Some  of  the  natural  mineral  s}orings,  both 
thermal  and  salt,  have  a  more  or  less  well-founded  reioutation  in  the  treat- 
ment of  this  class  of  cases. 

Finally,  certain  local  antibacterial  meastires  have,  in  recent  years,  been 
introduced  for  the  specific  local  treatment  of  granulating  inflammations. 
These  will  be  considered  under  the  head  of  the  special  diseases  in  which  they 
are  employed. 

The  Constitutional  Treatment  of  Inflammation. — AVhile  the  local 
treatment  of  inflammation  demands  our  first  and  greatest  care  because  of  the 
now  Avell-recognized  causes  of  the  processes  which  contribute  largely  if  not  ex- 
clusively toward  bringing  about  the  condition,  yet  the  constitutional  state  should 
not  be  neglected.  The  local  application  of  cold,  while  restricted  in  its  use, 
serves  at  the  same  time  as  a  general  refrigerant  measure.  The  application 
should  be  made  as  near  the  inflamed  part  as  possible.  Running  water  used  at 
room-temioerattire,  or  cooled  by  the  addition  of  ice,  is  the  most  useful.  A 
convenient  arrangement  for  the  purpose  is  the  ice-coil  (Fig.  17). 

The  administration  of  antipyretic  drugs  is  to  be  discouraged,  as  far  as 
possible,  in  the  treatment  of  surgical  infiammator}'  fever.  The  use  of  cpinin, 
formerly  so  extensively  employed,  is  now  limited  to  tonic  doses.  The  synthet- 
ically prepared  coal-tar  products  used  in  general  medicine  are  all  more 
or  less  harmful  in  surgical  practice,  first,  because  they  mask  the  real  condition, 
and,  second,  because  of  their  depressing  influence.     The  specific  or  granulating 


THK    TlfKAT.Ml'LN-r    OF    IXFI.A.MM Al'lOX 


65 


forms  of  indanimation  arc  not.  as  a  rule,  accompanied  by  very  marked 
fel)rile  disturbances,  except  possibly  for  a  brief  period  at  the  commence- 
ment of  the  infective  proc- 
ess. This  is  particularly 
true  of  syphilis.  General 
mercurial  treatment  is  in- 
dicated as  soon  as  the 
diagnosis  is  established. 
No  specific  has  been  dis- 
covered for  tuberculosis  and 
leprosy  analogous  to  that 
which  we  possess  for  syph- 
ilis. In  the  absence  of  this, 
e^'ery  effort  nmst  be  made 
to  build  up  the  tissues  in  a 
manner  calculated  to  render 
the  cellular  elements  resist- 
ant to  the  inroads  of  the 
specific  bacillus  on  which 
the  granulating  inflamma- 
tion depends.  For  this  purpose  rich  foods,  strengthening  wines,  and,  in  the 
case  of  tuberculosis,  residence  in  a  favorable  climate  should  be  recommended. 


Fig.   17. — Ice-coil. 


SECTION  II 
INJURIES  AND   DISEASES   OF   SEPARATE  TISSUES 

THE  SKIN  AND  SUBCUTANEOUS  CONNECTIVE  TISSUE 

CONTUSIONS  AND  OTHER  TRAUMATISMS 

Owing  to  the  great  elasticity  of  the  skin,  force  appHed  to  its  surface  by  a 
blunt  instrument  or  object  may  produce  a  solution  of  continuity  of  the  under- 
lying structures  without  producing  separation  of  the  skin  itself.  Crushing 
effects  may  also  lead  to  rupture  of  vessels  and  extensive  hemorrhage  into  the 
subcutaneous  cellular  tissue  (hematoma)  without  apparent  injury  to  the  skin 
itself.  The  presence  of  long  elastic  fibers  in  the  cutis  and  sulicutaneous  con- 
nective tissue  will  reasonably  account  for  this  power  of  resistance  to  injury 
which  the  skin  possesses.  Ciaping  of  the  wound  when  sharp-edged  instruments 
are  employed  is  also  accounted  for  by  this  elastic  property  of  the  skin. 

The  arrangement  and  extent  of  the  fibers  of  the  skin  are  not  the  same  in  all 
})ortions  of  the  surface  of  the  body.  In  the  extremities  they  pursue  a  course 
almost  parallel  to  the  limb;  on  the  trunk  they  are  irregularly  distributed 
as  regards  direction,  ^\'hile  about  the  palpebral  fissure  and  margins  of  the  oral 
opening  they  are  disposed  in  a  circular  manner  in  accordance  with  the  manner 
of  disposition  of  the  orbicular  muscles.  In  fact,  it  is  evident  that  the  elastic 
fibers  follow,  to  some  extent,  the  direction  of  the  muscular  fibers  of  the  part. 
The  pectoralis  major  and  latissimus  dorsi  show  this  plainly.  The  strictly 
longitudinal  direction  is  not  preserved  in  the  case  of  the  knee-joint  and 
elbow-joint.  Here  the  elastic  fibers  pass  around  the  patella  and  olecranon 
in  a  concentric  fashion. 

Gaping  of  Wounds. — The  manner  in  which  solutions  of  continuity  in  the 
surface  of  the  skin  will  gape  dejjends,  therefore,  on  the  location  of  the 
wound  and  the  direction  in  which  it  divides  these  fibers.  If  it  is  on  an 
extremity  and  passes  at  right  angles  to  the  direction  of  the  elastic  fibers,  there 
will  be  the  maximum  amount  of  gaping;  while  if  it  passes  in  the  same 
direction  as  the  fibers^  the  minimum  amount  will  be  produced ;  in  the  latter 
instance  but  few  fibers  are  severed ,  as  compared  with  the  former.  The  prox- 
imity of  the  wound  to  a  gingh-moid  joint  ^vill  likewise  govern  the  amount  of 
gaping.  Tension  on  the  convex  side  of  the  knee-joint  or  elbow-joint  will 
tend  to  increase  the  separation  of  the  wound  edges.  Wounds  of  the  sole  of 
the  foot  and  palm  of  the  hand  are  obser\'ed  to  gape  but  very  slightly,  for  the 
reason  that  in  these  regions  the  fibrous  structure  of  the  connective  tissue  is  so 
arranged  as  to  form  a  dense  attachment  between  the  papillary  body  and  the 
underlying  aponeurotic  structures.  This  will  explain  the  difficulty  which  the 
surgeon  experiences  in  turning  back  a  flap  in  these  localities  as  compared  with 
one  in  other  portions  of  the  bodv. 

G6 


SKIN    AND    SITRCITTANKOUS    CONNECTIVP]   TISSUE  67 

The  above  considerations  will  enable^  the  sui'geon  to  estimate  in  manv  in- 
stances the  amonnt  of  tension  which  it  is  necessary  to  make  on  the  wound 
edges  in  order  to  bring  about  perfect  approximation,  as  well  as  aid  in  the 
selection  of  a  proper  suture  material. 

Abrasions  of  the  Skin. — In  abrasions  of  the  skin  involving  but  little 
more  than  the  pai)illarv  layer  the  reparative  process  takes  place  rapidly  and 
patliologic  inflammation  does  not  occur.  The  injured  layer  of  the  rete  Mal- 
pighii  furnishes  a  few  drops  of  blood  and  exudation,  which,  mingling  together 
and  undergoing  coagulation,  cling  to  the  abraded  surface.  Evaporation  of 
its  watery  elements  leads  to  desiccation  of  the  mass,  and  the  typic  crust  or 
scab  is  formed.  This  serves  as  a  means  of  protection  to  the  underl}'ing  wound 
surface,  and  its  rapid  change  from  a  moist  to  a  dry  state  keeps  it  from  becom- 
ing a  favorable  pabulum  for  bacteria,  so  that  suppuration  is  prevented. 

In  this  method  of  repair,  called  healing  under  a  crust,  there  is  complete 
deA-elopment  of  the  epidermal  layer  beneath  the  incrustation,  when  the  latter, 
left  undisturbed,  is  permitted  to  fall  off  of  itself.  This  healing  is  possible  in 
a  natural  way  only  in  case  there  is  but  a  slight  amount  of  primary  wound 
secretions  and  in  situations  favorable  to  rapid  desiccation.  Attempts  to 
imitate  the  formation  of  the  crust  by  artificial  means  have  been  more  or  less 
successful  in  wounds  extending  into  the  subcutaneous  cellular  tissue  and 
involving  blood-vessels  and  lymph-channels.  Thus,  asepsis  being  assured, 
the  wound  has  been  hermetically  sealed  by  means  of  collodion,  with  or  -without 
the  addition  of  iodoform  (K  ii  s  t  e  r),  or  some  other  antiseptic  powder.  The 
latter  alone,  provided  it  is  sterile  and  the  wound  edges  are  brought  into  contact, 
is  quite  efficient.  Tn  fact,  am^  occlusive  method  Avhich  shuts  out  from  the 
wound  extraneous  and  irritating  matters  imitates  the  process  of  healing  under 
the  scab. 

Suppurative  Inflammation  of  the  Skin.— The  skin  may  take  on  sup- 
purative inflammation  from  infection  having  its  origin  in  a  wound.  This  is 
superficial  in  character  and  comparatively  harmless,  involving  only  the  rete 
Malpighii  and  the  papillary  body.  Owing  to  the  dense  character  of  the  parts 
involved,  rapidly  progressive  suppuration  is  impossible. 

Suppurative  Inflammation  of  the  Subcutaneous  Connective  Tis= 
sue. — Here,  without  aseptic  and  antiseptic  measures,  phlegmonous  conditions 
of  a  very  severe  character  are  easity  produced.  The  arrangement  of  the  elastic 
fibers  in  this  situation,  and  the  parallel  direction  of  the  lymph-current,  form 
favorable  conditions  for  the  propagation  of  phlegmonous  suppurative  inflam- 
mation. It  is  not  necessary,  however,  that  phlegmonous  inflammation  of  the 
subcutaneous  connective  tissue  should  have  its  origin  in  a  Avound  involving 
this  structure.  A  microorganism  of  sufficient  infecting  power  in  the  rete  Mal- 
pighii, Avhich  may  have  gained  entrance  therein  by  an  almost  microscopic 
breach  of  surface,  may  finally  reach  the  subcutaneous  connective  tissue,  where 
it  propagates  rapidly.  So-called  idiopathic  phlegmonous  inflammations  are 
to  he  accoimted  for  in  this  manner.  The  more  or  less  constant  coexistence 
of  lymphangitis  with  subcutaneous  cellulitis  renders  it  probable  that  the 
course  of  the  infection  is  along  the  lymph-channels.  The  simultaneous  in- 
volvement of  the  papillary  layer  and  rete  Malpighii  with  the  subcutaneous 
connective  tissue  constitutes  the  condition  known  as  erysipelatous  cellulitis, 
or  traumatic  erj^sipelas. 


68  INJURIES  AND  DISEASES   OF  SEPARATE  TISSUES 

Losses  of  substance  may  occur  in  the  skin  in  conseciuence  of  trauma, 
from  sloughing  as  a  result  of  the  injur>',  or  in  very  high  grades  of  phlegmo- 
nous inflammation.  Destruction  of  the  skin  likewise  follows  as  an  effect 
of  extreme  heat  and  cold  (burn  and  frost-bite)  and  as  a  result  of  ulceration. 
In  the  repair  which  takes  place  the  first  essential  is  the  proliferation  of  healthy 
granulations.  These  subsequently,  by  a  process  of  contraction,  approximate 
to  some  extent  the  margins  of  the  granulating  surface,  and  in  this  way  the  defect 
is  partially  corrected  by  the  neighboring  structures.  While  under  these  cir- 
cumstances the  displacement  of  neighboring  tissues  is  of  service  in  assisting  to 
supply  a  defect  caused  by  loss  of  substance,  some  very  serious  disadvantages 
ma}'  subsequently  follow,  as  Ave  shall  see  further  on.  In  addition  to  the  attempt 
at  closure  of  the  defect  by  cicatricial  shrinkage,  the  formation  of  an  epider- 
mal layer  is  needed  to  complete  the  process  of  repair.  This  formation  may 
take  place  rapidly  or  slowly,  and  the  resulting  epidermal  formation  may  be 
a  firm  and  solid  layer,  or  may  prove  to  be  thin  and  defective,  in  which  case 
further  aid  will  be  needed.  This  is  furnished  by  either  plastic  procedures  or 
skin  transplantation  (R  e  v  e  r  d  i  n  ,  Thiersch)  (see  page  328). 

THE  CICATRIX  AND  ITS  DISEASES 

Althougli  the  complete  cicatrix  is  intended  to  serve  the  purposes  of  the 
normal  structure  which  it  replaces,  it  is  never  identical,  either  anatomically 
or  functionally,  with  the  normal  structures.  When  recently  formed,  it  may 
break  down  and  take  on  inflammatory  conditions,  particularly  if  aseptic  pre- 
cautions have  been  neglected  during  the  healing  process. 

Abscesses  in  scar  tissue  may  result  from  the  presence  of  foreign  bodies, 
such  as  bone  spiculae,  or  portions  of  ligature  or  suture  material.  Suppura- 
tion from  the  presence  of  infectious  agents  may  occur  in  the  newly  formed 
tissue.  Ulceration  may  result  from  mechanic  causes,  such  as  friction  from 
the  clothing.  In  the  recent  cicatrix  this  may  heal  readily,  but,  later  on,  when 
the  rich  blood-supply  disappears,  ulceratiA-e  conditions  heal  but  slowly.  In 
addition,  injury  to  the  cicatrix  may  arise  from  its  unyielding  and  inelastic 
character,  solutions  of  continuity  occurring  more  readily  than  in  the  soft  and 
elastic  normal  structures. 

Pain  from  pressure  on  nerve-trunks  may  result  from  the  pressure 
of  dense  and  extensive  scar  tissue.  This  will  be  severe  and  persistent  accord- 
ing as  the  nerve-trunk  or  its  sheath  is  actually  involved  in  the  cicatrix,  or  as 
it  results  from  simple  pressure  or  tension  consequent  on  the  shrinking  of 
the  cicatrix. 

Cicatricial  Keloid. — The  causes  of  the  degenerative  changes  in  scar  tissue, 
knoAATi  as  keloid,  are  obscure.  Cicatricial  keloid  is  characterized  by  increased 
vascularity  of  the  scar,  together  with  growth  into  the  surrounding  tissues,  a 
tumor  resulting  A\-hich  is  verv  hard  and  has  a  reddish  color.  Extirpation  followed 
by  primar\^  union,  and  even  skin-grafting  or  transplantation,  does  not  prevent 
recurrence.  The  disease,  in  this  respect  at  least,  resembles  malignant  dis- 
ease. Electrolysis  (H  a  r  d  a  w  a  y)  and  continued  pressure  b\'  the  elastic 
bandage  (V  e  r  n  e  u  i  1)  are  recommended.  Multiple  scarifications  made 
at  intervals  of  a  sixteenth  of  an  inch  from  one  another,  crossed  so  as  to  form 
square  or  lozenge-shaped  figures,  deep  enough  to  reach  almost  to  the  depth 


SKIX    AXD    SUBCUTANEOUS    CONNECTIVE    TISSUE  69 

of  the  scrowth  and  long  enough  to  reach  just  beyond  its  borders,  should  be  tried, 
local  anesthesia  being  enij)l()yed.  The  parts  should  be  dressed  at  first  with  boric 
acid  solution,  and  twice  daily  applications  of  mercurial  plaster  should  be  com- 
menced on  the  day  following.  The  scarification  is  to  be  repeated  until  the 
growth  disappears.  Tlic  application  of  the  x-rays  has  been  recently  recom- 
mend(>d. 

Epithelioma  of  Cicatricial  Tissue. — Recurrences  in  operation  wounds 
following  extirpation  of  malignant  growths  are  not  to  be  classed  with  the  con- 
dition under  consideration.  True  cicatricial  carcinomas  are  to  be  divided 
primarily  into  two  groups:  (1)  those  having  their  origin  in  theretofore  un- 
changed and  typic  cicatricial  tissue;  (2)  those  occurring  in  cicatricial  tissue 
which  has  been  the  site  of  previously  existing  but  benign  ulcerative  processes. 
The  latter  group  includes  the  larger  number  of  cases.  The  sites  of  old  seton 
cicatrices,  leg  ulcers,  bone  fistulas  and  old  urinary  fistulas  about  the  penis,  scar 
tissue  in  the  rectum  and  along  the  lower  intestinal  tract  where  chsenteric  and 
old  tuberculous  and  other  ulcerative  conditions  have  previously  existed,  and 
old  parturient  lacerations  of  the  cervix  uteri  are  favorite  locations  for  the  dis- 
ease. It  may  occur  on  the  granulating  surface  of  cicatricial  tissue  which 
has  never  been  covered  with  normal  epithelium.  The  disease  develops,  as  a 
rule,  where  the  greatest  amount  of  tension  exists  in  the  scar,  when  efforts  are 
made  to  reduce  deformities  due  to  the  latter,  and  at  the  site  of  ulceration  from 
injur}-.  Applications  to  the  latter  of  nitrate  of  silver  or  of  other  cauterizing 
agents  may  contribute  toward  the  result.  It  inclines  to  spread  on  the  sur- 
face, and  rareh'  passes  into  the  depths  of  the  tissues :  when  the  latter  condition 
occurs,  an  extremely  malignant  form  of  the  disease  is  present.  The  treat- 
ment consists  in  early  and  radical  extirpation.  Amputation  of  an  extremity 
offers  a  better  prognosis  than  ablation  of  the  ulcer  and  its  surroundings. 
Primary-  union  should  be  obtained;  existing  defects  should  be  corrected  at 
once  by  accurate  coaptation  and  plastic  procediu'es  when  necessaiy. 


ULCERATION  OF  THE  SKIN 

By  ulceration  is  meant  that  process  in  which  the  tendenc}-  to  progressive 
suppurative  destruction  of  tissue  is  greater  than  the  tendency  to  granulation. 
The  resulting  condition  is  called  an  ulcer.  Ulcers  may  be  divided  into  three 
groups.  The  first  includes  those  which  arise  from  disturbances  of  the  circu- 
lation. The  second  embraces  those  in  which  an  ulcerative  process  is  engrafted 
on  a  granular  inflammation  (syphilis,  tulDerculosis,  leprosy).  The  third  is 
composed  of  cases  in  wliich  an  iflcerati^e  condition  supen-enes  in  certain 
neoplasms,  notably  those  of  a  malignant  character.  In  the  first  group  the 
\'ascular  error  may  be  (1)  a  local  anemia  arismg  from  some  intert'erence  vrith 
the  arterial  current :  (2)  a  local  congestion  due  to  intert'erence  with  the  return 
circulation.  A  slight  traumatism  or  an  eczematous  vesicle,  through  which 
irritating  or  putrefactive  agents  have  entered,  may  give  rise  to  an  ulcer,  repair 
or  the  formation  of  normal  granulation  tissue  being  rendered  difficult  by  the 
disturbances  of  the  circulation.  Besides  the  ulcers  which  occur  in  conditions 
W  enfeebled  circulation  and  varices,  varicose  ulcers  may  arise  from  inflam- 
matory conditions  involving  the  dilated  veins  themselves. 

Ulceration  from  Pressure ;  Bedsores. — A  necrosis  of  portions  of  tis- 


70  INJURIES    AND    DISEASES    OF   SEPARATE   TISSUES 

sue  that  have  been  exposed  for  a  considerable  time  to  pressure,  occurring  in 
those  lying  in  bed,  or  in  certain  paralyses  of  cerebral  or  spinal  origin  in  which 
the  pressure  is  neither  considerable  nor  prolonged,  constitutes  the  classic  type 
of  ulcer  known  as  bedsore  or  decubitus.  The  position  of  these  bedsores  will 
vary  Avith  the  position  of  the  patient.  They  are  usually  confined  to  the  skin 
overlying  projecting  bony  points.  In  the  dorsal  position  the  sacrum,  coccyx, 
and  tuber  ischii  are  the  most  prominent  points.  The  skin  over  the  spines  of 
the  scapulae,  the  occiput,  and,  in  the  lateral  position,  the  trochanter  major  and 
the  malleoli  may  suffer.  If  the  patient  lies  on  the  abdominal  surface,  bed- 
sores may  appear  on  the  anterior  superior  spinous  processes  of  the  ilium,  chin, 
and  forehead.  Pressure  of  the  bed-covering  alone  may  produce  bedsores, 
the  extremity  of  the  toes  and  the  prepatellar  regions  suffering.  Fever  is  a 
predisposing  cause  of  bedsores;  with  the  subsidence  of  the  fever  the  ulcera- 
tion may  take  on  a  healthy  action  or  heal  entirely,  only  to  recur  upon  relapse. 

The  appearances  present  when  a  bedsore  is  about  to  occur  are  character- 
istic, consisting  of  a  reddish  discoloration  of  the  skin  at  the  point  of  pressure, 
followed  by  a  bluish  tint  ^vhich  afterward  changes  to  browm  or  black.  The 
resulting  destructive  process  involves  the  entire  thickness  of  the  skin,  and 
even  the  underlying  structures  to  the  bone.  A  suppurative  and  putrefac- 
tive process  occurs  coincidentally  in  some  cases;  in  others,  after  a  longer  time 
more  or  less  oval  or  round  defects  of  tissue  are  produced,  which,  in  some 
instances,  are  never  restored,  and  in  others  occupy  months  in  the  healing 
process. 

The  treatment  of  the  class  belonging  to  the  first  group  of  ulcers,  arising 
from  disturbances  of  the  circulation  (varicose  ulcers),  consists  (1)  in  cor- 
recting as  far  as  possible  the  disturbed  conditions  of  the  circulation  on 
which  the  ulcer  depends;  (2)  in  affording  even  and  firm  support  to  the 
vessels  of  the  part,  in  order  to  minimize  as  much  as  possible  the  tendency 
to  stasis.  Elevation  of  the  limb,  with  the  patient  in  the  horizontal  position, 
wheneA'er  this  is  possible,  is  of  material  service  in  fulfilling  the  first  indication, 
and  systematic  strapping  and  bandaging  fulfil  the  second.  In  carrying  out  the 
latter,  all  antiseptic  conditions  should  be  complied  with.  Thorough  shaving 
and  scrubbing  of  the  neighborhood,  and  irrigating  with  sublimate  solution, 
should  precede  the  application  of  the  strapping.  In  case  a  hard  elevated 
ridge  circumscribes  the  ulcer,  or  a  dense  fibrous  floor  exists,  it  will  be  neces- 
sary first  to  incise  these  thoroughly  in  order  that  the  vessels  beyond  and  be- 
neath the  area  of  the  ulcer  may  be  permitted  to  find  their  way  into  the  latter 
and  convey  suitable  nourishing  material  for  the  purpose  of  repair  (L.  A. 
S  a  y  r  e) .  These  incisions  should  be  made  about  a  quarter  of  an  inch 
apart,  in  the  direction  of  the  long  axis  of  the  limb,  and  should  penetrate  well 
through  the  hard  fibrous  floor  above  mentioned.  An  anesthetic  is  not  neces- 
sary, under  ordinary  circumstances,  as  the  incisions  can  be  rapidly  made, 
and  the  parts,  as  a  rule,  are  not  very  sensitive.  Bleeding  having  ceased, 
whatever  blood  remains  on  the  surrounding  skin  should  be  carefully  wiped 
away  by  means  of  a  bit  of  dry  sterilized  gauze,  while  any  clots  which  cling 
to  the  edges  of  the  incision  or  remain  on  the  ulcerated  surface  should  be 
left  undisturbed.  These  blood-clots  will  form  an  arbor  or  trellis- work,  through 
the  medium  of  which  the  surrounding  and  underlying  vessels,  which  now 
have  access  from  the  cut  edges  of  the  incisions,  will  penetrate  and  form  new 


SKIN    AND    SUBCUTANEOUS    CONNECTIVE    TISSUE 


71 


granulation  niatprial.  The  circulation  in  the  foot  should  be  supported  by 
either  a  snug  flannel  bandage  or  circular  strips  of  adhesi\'e  plaster,  sys- 
teniaticalh'  aj^plied.  These  may  reach  to  ^\-ithin  about  two  inches  of  the 
edge  of  the  ulcer.  The  ulcer  itself  is  to  be  strapped  in  so-called  "basket  strap- 
ping." This  consists  of  strips  of  diachylon  or  resin  plasters,  cut  in  lengths 
about  one  inch  less  than  will  be  sufficient  to  encompass  the  limb  and  not 
more  than  one  inch  A\ide.  When  practicable,  it  is  better  to  cut  the  strips 
crosswise  to  the  piece  as  it  is  furnished  b}-  the  manufacturer.  This  facilitates 
their  smooth  application.  Each  strip,  at  the  moment  of  application,  is  heated 
over  the  alcohol  lamp.  This  sterilizes  the  surface  which  is  to  be  applied  to 
the  ulcer,  and  at  the  same  time  increases  its  adhesiveness.  The  first  strip  is 
applied  horizontally,  and  just 
overlaps  the  upper  bound- 
ar}'  of  the  flannel  bandage; 
it  encircles  the  limb.  The 
next  strip  is  placed  verti- 
cally, or  at  right  angles  to 
the  above,  and  is  likewise 
placed  at  least  two  inches 
from  the  nearest  border  of 
the  ulcer.  The  next  strip  is 
placed  horizontally,  and  half 
overlaps  the  first.  The  next 
or  fourth  strip  is  placed  verti- 
cally and  half  overlaps  the 
second,  or  the  vertical  strip 
which  has  preceded  it.  The 
process  is  now  continued  in 
the  same  manner,  alternate 
horizontal  and  vertical  strips 
being  applied  until  the  entire 
surface  of  the  ulcer  is  gradu- 
ally covered.      (See  Fig.  18.) 

The    strapping  is  carried  well  Fig.  is.— basket  Strapping  and  Ulcer  of  the  Leg. 

ab0\'e    and    bevond   the    mar-        •      ^    Bandage  applied   to  foot  and  ankle;  B    basket  strap- 
ping; O,  portion  oi    ulcer  remaining    uncovered;    D,   incisions 
gmS  of  the  ulcer.      An  antisep-     through  base  and  edges  of  ulcer. 

tic  compress,  made  of  crum- 
pled gauze  and  large  enough  to  cover  and  overlap  the  plaster  strapping,  is  now 
placed  over  the  latter,  and  over  all,  including  the  flannel  bandage  of  the  foot,  a 
roller  bandage  is  firmly  applied.  Should  no  discharge  or  other  evidences  of  dis- 
t'lrbances  occur,  the  dressings  should  be  allo^^■ed  to  remain  for  from  ten  to  four- 
teen days;  the  patient,  as  a  rule,  is  permitted  to  walk  about.  At  the  end  of 
this  time  the  bandage  and  plaster  are  to  be  slit  up  T^dth  a  pair  of  bandage 
scissors,  care  being  taken  in  doing  this  to  select  a  point  suflficiently  far  from 
the  site  of  the  ulcer  in  order  to  avoid  injuring  this  with  the  scissors.  The 
bandages  and  plaster  are  now  removed,  the  latter  peeling  off  like  the  bark 
of  a  tree.  Some  tenacious  secretion  from  the  ulcerated  surface  will  be  found 
on  the  plaster,  as  well  as  on  the  neighboring  skin.  From  the  latter  situa- 
tion it  may  be  removed  with  a  piece  of  sterilized  gauze ;  on  no  account  should 


72  INJURIES    AND    DISEASES    OF    SEPARATE   TISSUES 

the  gauze  l^e  permitted  to  come  in  contact  with  the  nicer  itself.  In  lieu  thereof 
a  gentle  stream  of  a  mild  antiseptic  solution  (boric  acid  1  :  1000)  should  be 
allowed  to  flow  over  the  surface  of  the  ulcer  until  it  is  thoroughly  cleansed. 
A  striking  change  will  be  found  to  have  taken  place  in  the  ulcer.  In  place 
of  the  hard  and  elevated  edge,  A\hich  will  be  found  to  have  disappeared,  there 
is  a  soft  flattened  margin,  from  which  a  white  or  pale  l:)lue  line  of  new  epi- 
dermis is  already  forming.  The  hard  and  smooth  floor  Avill  have  given  place 
to  a  bed  of  soft  and  healthy  granulations.  The  incisions,  where  they  cross 
the  margins,  gape  widely  and  are  filled  with  healthy  granulations.  The 
antiseptic  solution  is  not  to  be  dried  from  the  surface  of  the  granulation ;  only 
the  surrounding  skin  is  to  be  dried.  Precisely  the  same  course  is  now  fol- 
lowed as  at  first. 

It  may  happen  that  the  first  dressings  will  need  replacing  before  the  time 
specified  above,  owing  to  the  occurrence  of  discharge  through  the  bandage; 
it  is  rare,  however,  that  a  bandage  cannot  remain  on  at  least  a  week.  Two 
or  three  dressings,  except  in  exceptionally  large  ulcers,  usually  suffice,  when 
the  epidermal  layer  is  found  to  have  completely  co\'ered  the  granulating  sur- 
face, and  the  cure  is  complete.  The  patient  should  thereafter,  in  order  to 
escape  relapse,  wear  a  silk  elastic  stocking  to  support  the  circulation  in  the 
part,  care  being  taken  in  the  beginning  to  place  a  piece  of  soft  linen  or  lint 
over  the  newly  formed  cicatrix  in  order  that  this  may  not  become  irritated 
and  renewed  ulceration  occur.  In  case  of  the  latter  the  skin-grafting  method 
of  R  ever  din  or  that  of  Thiersch  should  be  employed.  (Plastic 
operative  procedures,  skin  transplantation,  etc.,  will  be  described  under  the 
head  of  Operations  on  the  Skin.)  Although  chronic  ulcers  of  the  extremity 
are  far  more  amena]:)le  to  treatment  now  than  formerly,  there  are  still  cases 
which  are  intractable,  suggesting  malignant  disease.  Still  others  extend 
deeply  and  involve  the  periosteum,  necrosis  resulting.  In  these  cases,  as  well 
as  in  some  instances  which  involve  the  entire  circumference  of  the  leg  (cir- 
cular ulcer),  other  measures  failing,  the  resort  to  amputation  is  justifiable. 

Treatment  of  Bedsores. — Early  measures  should  be  taken  to  prevent 
ulceration  from  pressure  in  the  sick  and  disabled.  This  may  be  accomplished, 
in  the  majority  of  cases,  by  the  judicious  use  of  elastic  cushions  to  distribute 
pressure,  by  occasional  bathings  with  alcohol  and  water,  and  by  the  use  of 
ring-shaped  air  or  water  cushions,  when  ulceration  threatens  or  is  in  progress. 
An  occasional  change  of  position  will  likewise  be  useful.  Allien  ulceration 
occurs,  this  should  be  treated  antiseptically,  with  1  :  1000  sublimate  solu- 
tion, after  which  the  ulcerated  surface  should  be  powdered  Avith  naphthalin 
and  iodoform  in  eriual  proportions  and  dressed  with  antiseptic  gauze.  The 
resulting  separation  of  sloughs  may  be  hastened  by  the  vigorous  use  of  the 
curet.  Health}-  granulations  follow  as  a  result  of  this  treatment,  and,  these 
once  established,  the  use  of  iodoform  gauze  or  Peruvian  balsam  and  naph- 
thalin gauze  as  a  dressing  Avill  result,  in  most  cases,  in  final  healing.  Oc- 
casionally iodoform  ointment  or  Peruvian  balsam  on  gauze  is  found  to  be 
a  useful  dressing.  \"arious  astringents,  such  as  nitrate  of  silver,  chlorid  of 
zinc,  or  preparations  of  lead,  are  also  employed,  as  well  as  some  of  the  mer- 
curial ointments,  particularly  a  diluted  ointment  of  the  red  oxid  of  mercury. 
An  exceedingly  valuable  combination  consists  of  1  part  of  nitrate  of  silver, 
5  parts  of  Peruvian  balsam,  and  20  parts  of  simple  ointment.     Sometimes 


SKIN   AND    SUBCUTANEOUS    CONNECTIVE   TISSUE  73 

considerable  time  may  be  sa^-ed  by  freslieniiig  the  edges  of  the  ulcer,  detach- 
ing the  soft  parts  for  some  distance  beyond  the  edges,  and  bringing  the  mar- 
gins in  more  or  less  close  ajjproximation  by  silkworm-gut  or  silver  wire  sutures. 
After  preliminary  curetting  and  antiseptic  treatment,  filling  the  ulcer  cavity 
with  a  blood-clot  obtained  by  scarifying  the  granulations,  and  dressing  by 
means  of  oiletl  silk  protective  and  antiseptic  dressings  (the  so-called  healing 
by  organization  of  the  clot,  Schede),  or  sponge  grafting,  has  proved  of 
service.  Finally,  these  ulcers,  like  those  on  the  leg,  may  be  treated  by  a 
circumscribing  incision  (Nussbaum),  incision  of  the  boundaries  and 
floor,  and  by  skin  transplantation. 


EFFECTS  OF  HEAT  AND  COLD 

Certain  physical  and  chemic  disturbances  occur  alike  as  the  result  of  ex- 
cessive heat  and  cold.  The  inflammatory  conditions  present  are  not  essen- 
tial but  accessory.  These  disturbances  consist  of  changes  in  the  skin  and 
circulating  channels,  which  vary  according  to  the  temperature  and  length 
of  time  of  exposure  of  the  part. 

Degree  of  Burns. — A  momentary  exposure  to  a  temperature  at  or 
just  below  the  boiling-point  of  water  produces  a  simple  paralysis  of  the  con- 
strictor muscles  of  the  smaller  arteries,  and  a  consequent  overfilling  of  these. 
The  increased  quantity  of  blood  which  results  from  this  occasions  the  red- 
ness observed  under  these  circumstances;  this  is  known  as  a  burn  of  the 
first  degree.  Burns  of  the  second  degree  are  those  in  which  blistering 
takes  place,  the  j^arts  being  exposed  for  a  greater  length  of  time  or  to  a  higher 
temperature.  Here  there  is  an  exudation  of  serous  fluid  into  the  tissues, 
and  particularly  into  the  rete  Malpighii;  portions  of  the  epidermal  la}-er  are 
lifted  up,  constituting  the  covering  of  the  blister.  More  lengthy  exposure 
to  the  temperature  of  boiling  water  induces  albuminous  coagulation  affecting 
the  contents  of  the  vessels,  together  with  the  serous  fluid  and  albuminous 
substances  of  the  tissues.  Owing  to  this  interference  with  the  normal  struc- 
ture, greater  or  lesser  areas  are  deprived  of  nourishment,  and  hence  necrosis 
of  tissue  constituting  a  burn  of  the  third  degree  is  the  result.  The  dead 
tissue  presents  a  '\\^hite  appearance  from  coagulated  albumin.  In  case  of 
exposure  to  a  stifl  higher  grade  of  heat,  as,  for  instance,  on  the  application 
of  a  glowing  hot  iron,  the  destro}'ed  tissue  may  assume  a  blackish  tint. 
Some  authors  make  a  fourth  and  even  a  fifth  degree  of  burn.  These  are, 
however,  simply  the  third  degree  exaggerated,  and  constitute  charring  either 
of  the  skin  or  of  this  and  the  muscular  structures  as  well. 

Prognosis  of  Burns.— The  involvement  of  large  areas  of  the  surface  in 
burns  of  the  second  and  third  degree  involves  direct  danger  to  life.  Bums 
of  the  first  degree  in  very  young  children  ma}',  even  if  of  but  limited  extent, 
prove  fatal.  Still  smaller  areas  of  the  second  and  third  degree  may  also 
result  fatally.  Mere  reddening  of  more  than  two-thirds  of  the  body,  or  a 
burn  of  the  first  degree,  in  an  adult  may  destroy  life,  while  one-third  of  the 
surface  burned  to  the  second  or  third  degree  will  almost  inevitably-  j^roduce 
death.  Locality  will  to  some  extent  govern  the  prognosis.  A  lesser  area 
in  the  abdominal  and  thoracic  regions  is  to  be  regarded  more  seriously  than 
a  larger  extent   of  surface   on  the   extremities.     Death   may  result  directly 


74  INJURIES   AND   DISEASES   OF   SEPARATE   TISSUES 

from  shock.  Overstimulation  of  the  superficial  sensory  nerves  may  produce 
death  by  reflex  cardiac  paralysis  (S  o  n  n  e  n  b  u  r  g).  After  reaction,  con- 
gestion of  internal  organs  from  vasomotor  paresis  may  occur;  it  is  probable, 
however,  that  excessi\'e  destruction  of  the  red  blood-corpuscles  and  their 
conversion  into  small  globules  (M  ax  S  c  h  u  1 1  z  e)  are  more  frecjuently 
the  cause  of  blood-stasis  in  internal  organs.  The  secondary  dangers  relate 
to  prolonged  suppuration,  exhaustion,  erysipelas,  pyemia,  septicemia,  and 
tetanus.  Perforating  ulcer  of  the  duodenum  has  been  observed  as  a  second- 
ary complication  of  burns.  Edema  of  the  glottis  from  scalds  of  the  mouth 
is  an  occasional  fatal  complication. 

Excessive  Cold,  or  Frost=bite. — When  the  temperature  of  the  skin  is  con- 
siderably lowered,  the  constrictor  muscular  apparatus  of  the  small  arteries 
contracts.  If  this  occurs  suddenly,  the  blood  is  shut  off  from  the  respective 
areas  of  distribution,  and  a  blanching  of  the  surface  is  observed  as  a  result  of 
the  local  anemia.  This  is  seen  in  the  ear  and  nose  when  exposed  to  a  low  tem- 
perature. As  a  rule,  however,  this  takes  place  slowly,  and  the  flow  of  blood 
through  the  parts  continues,  though  imperfectly.  In  affected  regions  re- 
mote from  the  center  of  circulation  greater  difficulty  is  experienced  by  the 
heart  in  forcing  the  blood  into  the  larger  veins,  and  hence  in  these  parts  (the 
hands  and  feet)  the  earliest  and  most  destructive  effects  of  frost-bite  are  ob- 
served. In  the  venous  stasis  which  marks  the  first  degree  of  frost-bite,  the 
discoloration,  unlike  the  redness  in  the  first  degree  of  bums  and  scalds,  is  of  a 
bluish  tint.  This  difference  arises  from  the  fact  that,  in  the  case  of  a  burn, 
the  redness  is  the  result  of  an  arterial  flux,  -while,  on  the  other  hand,  the  dis- 
coloration in  the  first  degree  of  frost-bite  results  from  venous  stasis.  The 
second  degree  of  frost-bite  is  characterized  by  the  formation  of  small  vesicles. 
If  the  lowered  temperature  of  the  parts  persists,  the  resulting  stasis  forces 
the  blood-serum  from  the  capillaries  and  smaller  veins.  This  accumulates  in 
the  rete  Malpighii,  and,  elevating  here  and  there  the  horny  layer  of  the  epi- 
dermis, results  in  the  formation  of  blisters.  Unlike  the  vesicles  resulting  from 
bums,  these  are  filled  with  straw-colored  fluid  or  reddish  liquid,  due  to  the 
presence  of  red  blood-corpuscles  in  greater  or  lesser  number.  In  the  third 
degree  of  frost-bite,  like  that  of  burn,  more  or  less  destruction  of  the 
skin  by  necrosis  occurs.  A  persistent  venous  stasis  is  followed  by  gangrene, 
which  differs  in  color  from  that  following  a  burn.  In  the  latter,  the  skin 
assumes  a  white  appearance  from  albuminous  coagulation,  or  a  black  hue  from 
actual  carbonization  or  charring.  In  the  third  degree  of  frost-bite  the  color 
of  the  necrotic  portion  is  dark  bro\^Ti.  This  arises  from  the  fact  that,  owing 
to  the  venous  stasis,  a  large  amount  of  blood-pigment  is  i.mprisoned  in  the 
part  as  gangrene  takes  place.  Later  on,  as  putrefactive  changes  occur,  this 
dark  brown  color  deepens  into  black. 

Prognosis  of  Excessive  Cold,  or  Frost-bite. — Excessive  cold  endangers 
life  in  proportion  to  the  length  of  time  of  exposure  and  the  extent  of  surface 
involved.  Muscular  rigidity  alone  ma}'  produce  death.  The  most  important 
factor  in  producing  immediate  death,  however,  is  the  destructive  changes  which 
the  blood-corpuscles  undergo,  exposed,  as  they  are  in  venous  stasis,  for  a  long 
time  to  the  effects  of  excessive  cold.  In  consequence  of  these  changes  they 
lose  their  function  as  oxygen-bearers.  It  is  probable  also  that  when  a  large 
mass  of  blood-corpuscles  thus  altered  is  permitted  to  enter  the  general  cir- 


SKIN    AND    SUBCUTANEOUS    CONNECTIVE   TISSUE  75 

dilation,  the  frozen  part  being  too  rapidly  restored,  the  blood-corpuscles  may 
accumulate  in  internal  organs  and  exert  a  deleterious  influence  on  the  entire 
economy.  This  is  a  rational  explanation  of  the  fact  that,  in  persons  who  have 
been  exposed  to  excessive  cold  with  resultant  frost-bite,  the  frozen  parts  cannot 
be  subjected  to  the  action  of  heat  without  great  risk,  but  must  be  treated  rather 
by  cold  applications,  such  as  friction  with  snow  or  ice-^\•ater  in  a  cold  room,  the 
change  to  a  warmer  atmosphere  being  brought  about  gradually.  Thus  the 
whole  mass  of  altered  blood-corpuscles  is  not  at  once  precipitated  into  the  cir- 
culation, but  rather  admitted  gradually. 

Inflammatory  Conditions  Following  Burns  and  Frost=bite.— Burns 
of  the  first  degree  somewhat  resemble  in  appearance  an  inflammation  of  the 
structures  affected.  But  the  differences  become  apparent  when  it  is  observed 
that  the  former  disappear  spontaneously  after  a  very  short  time.  In  burns 
of  the  second  and  third  degrees,  however,  opportunities  are  afforded  for  the 
entrance  of  microorganisms.  In  the  former,  if  the  vesicles  are  not  disturbed 
healing  may  take  place  beneath  the  raised  outer  layer  constituting  the  surface 
of  the  blister.  Usually,  however,  these  are  ruptured,  and  more  or  less  infec- 
tion takes  place  as  a  consequence,  inflammatory  complications  following.  In 
burns  of  the  third  degree  the  infection  does  not,  as  a  rule,  take  place  in  the 
area  of  charred  tissue,  since  here  the  usual  and  readiest  channels  of  infection 
are  closed,  but  from  the  margins  of  the  burn,  which,  as  a  rule,  are  not  carbon- 
ized, but  the  seat  of  a  burn  of  the  second  degree.  At  this  point  a  slowly  pro- 
gressive suppurative  inflammatory  process  goes  on,  the  neighboring  structures 
partaking  of  this  to  a  greater  or  lesser  extent;  this  is  what  is  known  as  the 
suppuration  of  demarcation,  and  marks  the  site  of  the  so-called  line  of  de- 
marcation. By  means  of  it  the  necrotic  tissue  is  slowly  lifted  and  separated 
from  the  living  structures  beneath.  A  phlegmonous  inflammatory  condition 
may  replace  the  suppuration,  in  which  case  the  line  of  demarcation  is  not  formed 
at  the  site  of  the  original  injury,  but  an  inflammatory  necrosis  may  become 
associated  with  that  arising  from  the  burn;  in  this  way  larger  areas  of  tissue 
become  involved  in  the  gangrenous  process.  With  the  early  employment  of 
antiseptic  measures,  however,  the  suppuration  of  demarcation  is  not  always 
observed.  The  charred  portion  does  not  form  a  favorable  soil  for  the  develop- 
ment of  bacteria,  owing  to  the  coagulation  of  its  albuminous  elements.  If, 
therefore,  the  entrance  of  bacteria  can  be  prevented  at  the  margins,  the  entire 
separation  of  the  necrotic  portion  may  occur  without  any  trace  of  suppuration. 
The  white  blood-corpuscles  do  not  migrate ;  new  vessels  are  formed,  and,  the 
young  vascular  connective  tissue  crowding  toward  the  necrotic  tissue,  an  asep- 
tic granulation  process  takes  the  place  of  the  suppuration  of  demarcation. 

Similarly,  in  the  first  degree  of  frost-bite  true  inflammatory  conditions 
are  not  present.  Even  though  increased  heat  is  present  as  a  result  of  reaction 
the  arterial  flux  is  soon  replaced  by  the  normal  state.  But  the  vesicles  which 
form  in  frost-bite  in  the  second  degree  may  become  the  medium  of  infection 
and  subsequent  inflammation  may  occur,  precisely  as  in  burns,  though  not 
so  readily  nor  to  the  same  extent.  The  occurrence  of  chilblain  or  pernio, 
however,  is  common,  particularly  about  the  fingers  or  toes,  as  well  as  about 
the  nose,  ears,  and  lips.  This  is  usually  induced  by  the  patient's  coming  too 
suddenly  in  contact  with  warm  air  after  frost-bite,  and  is  particularly  liable  to 
occur  in  children  and  feeble  persons. 


76  IXJUIUES    AND    DISEASES   OF   SEPARATE   TISSUES 

Frost-bite  of  the  third  degree,  however,  offers  the  coiHlitions  favoral^le 
to  the  rapid  occurrence  of  infection,  and  hence  of  inflammation,  rnhke  a 
burn  of  the  same  degree,  the  tissues  are  filled  with  blood  in  a  passive  state, 
the  albuminous  elements  are  not  coagulated,  and  the  necrotic  tissues  offer  the 
three  cardinal  conditions  favorable  to  germ  proliferation  and  putrefaction, 
namelv,  warmth,  moisture,  and  putrescible  organic  matter.  The  surrounding 
zone  of  venous  stasis  offers  a  fertile  field  for  bacterial  invasion  and  prolifera- 
tion, together  with  rapid  death  of  the  parts.  These  in  their  turn  undergo 
putrefaction,  and  thus  the  progressive  gangrene  extends  a  considerable  dis- 
tance beyond  the  apparent  area  originally  involved  in  the  frost-bite.  Unless, 
therefore,  an  early  antiseptic  course  is  followed  in  the  treatment,  extensive 
and  severe  septic  conditions  may  complicate  the  original  frost-bite.  Finally, 
a  line  of  demarcation  may  occur  here  as  in  the  gangrene  following  bums  of 
the  third  degree,  and  the  same  process  of  elimination  of  the  dead  parts  may 
take  place. 

Bums  of  the  second  and  third  degrees  involving  movable  parts  are  fre- 
quently followed  by  deformities  resulting  from  subseciuent  contraction  and 
shortening  of  the  cicatrix.  These  are  particularly  distressing  when  occurring 
in  the  facial  region,  wdiere  they  are  greatly  increased  by  the  involvement  of 
the  platysma  myoides,  the  anterior  portion  of  the  neck  and  the  upper  portion 
of  the  chest,  and  in  the  flexures  of  the  joints. 

The  Treatment  of  Burns  and  Frost=bite.  — As  far  as  the  immediate 
treatment  of  bums  and  frost-bite  is  concemed,  inasmuch  as  inflammatory 
conditions  are  not  necessarily  present,  the  employment  of  antiphlogistic  agents 
is  useless.  The  influx  of  blood  to  the  parts  in  the  burn  soon  disappears,  and 
the  coagulation  and  exudation  are  alone  to  be  considered.  In  frost-bite,  how- 
ever, the  venous  stasis  is  more  permanent,  and  measures  to  support  the  venous 
circulation,  if  an  extremity  is  affected,  are  indicated.  In  addition  to  this, 
chilblain  or  pernio,  which  may  follow  frost-bite  of  the  first  or  second  degree, 
is  to  be  treated.  This  may  amount  to  a  chronic  stasis,  for  which  warm  baths 
may  be  usefid  to  hasten  the  venous  circulation.  Again,  friction  with  snow 
or  ice-water  will  be  found  serviceable.  Liniments  containing  oil  of  turpen- 
tin,  diluted  hydrochloric  acid  (4  :  100),  or  the  applications  of  collodion  are  use- 
ful in  this  condition.  A  favorite  stimulating  application  consists  of  tincture 
of  cantharides  one  part,  and  soap  liniment  three  parts  (Wardrop). 
When  itching  or  burning  sensations  are  prominent  symptoms,  a  2.5  per  cent 
solution  of  carbolic  acid,  to  which  is  added  tincture  of  opium  in  the  proportion 
of  an  ounce  to  the  pint,  will  i^rocure  relief.  In  chronic  cases  in  which  the  skin 
becomes  thickened,  equal  parts  of  the  tincture  of  iodin  and  glycerin  may  be 
employed.  Oil  of  peppermint,  pure  or  diluted  with  six  times  its  bulk  of 
glycerin,  is  also  successfully  used.  In  chronic  cases,  or  those  which  have  a 
persistent  tendency  to  recurrence,  the  galvanic  current  has  been  advantage- 
ously employed.  In  the  mild  and  superficial  forms  of  ulceration  which  may 
follow  chilblain,  the  employment  of  a  carbolic  acid  or  creosote  ointment,  or 
other  combined  antiseptic  and  stimulating  application,  \\\\\  be  indicated. 

In  cases  of  bums  as  well  as  in  those  of  frost-bite,  where  the  slightest  vesi- 
cation occurs,  the  practitioner  should  bear  in  mind,  as  the  first  indication  for 
treatment,  the  necessity  for  early  aseptic  and  antiseptic  measures.  The  ex- 
tent and  severity  of  the  resulting  inflammatory  complications  will  be  in  direct 


SKIN    AND   SUBCUTANEOUS    CONNECTIVE    TISSUE  77 

proportion  to  the  amount  of  infection  which  occurs.  Tlic  old-fashioned 
methods  designed  to  shut  out  tlic  atmospheric  air,  such  as  dusting  the  parts 
with  flour,  or  covering  them  witli  ^-adding  ^^•ith  or  without  the  employment 
of  oil>-  compounds,  were  useful  in  that  they  prevented  to  some  extent  bacterial 
infection  and,  by  j^romoting  rapid  drying  of  the  exudates,  deprived  the  micro- 
organisms of  material  fa^'orable  for  their  support  and  proliferation.  The  use 
of  equal  parts  of  lime-water  and  linseed  oil  (carron  oil)  also  acted  by  affording 
protection.  These  may,  however,  be  profitably  replaced  by  antiseptic  irriga- 
tion, followed  by  the  application  of  antiseptic  dressings,  both  to  the  vesicles  which 
are  still  entire  and  to  those  which  haxe  been  accidentally  opened.  Antiseptic 
powder  dressings  (iodoform,  zinc  oxid,  bismuth  subiodid,  etc.)  may  be  employed, 
with  or  without  the  addition  of  gauze  material  impregnated  with  the  same. 
Supporting  measures  and  remedies  designed  to  relieve  pain  in  se^'ere  cases 
form  necessary  adjuncts  to  the  treatment. 

In  cases  in  which  extensive  and  deep  gangrenous  areas  are  present,  involv- 
ing, for  instance,  a  considerable  portion  of  a  limb,  removal  by  amputation 
will  become  necessar}\  The  dissecting  away  of  sloughs,  in  order  to  get  rid 
of  putrefying  masses  as  rapidly  as  possible,  is  always  indicated,  and  should 
be  practised  wherever  feasible  for  this  reason,  as  well  as  for  the  purpose  of  ob- 
taining access  to  the  parts  beneath  for  more  thorough  antisepsis.  In  making 
antiseptic  applications  to  extensively  denuded  or  large  granulating  surfaces 
the  poisonous  character  of  some  of  these  agents  should  be  borne  in  mind.  When 
wet  dressings  are  indicated  the  borosalicylic  solution  of  T  h  i  e  r  s  c  h 
(page  61)  should  be  employed.  For  a  dry  dressing  either  salicylic  gauze  or 
oxid  of  zinc  gauze  is  useful.  With  the  clearing  away  of  the  vesicles  and  sloughs 
an  ointment  dressing  best  fulfils  the  indications.  Boric  acid  ointment,  or  an 
ointment  consisting  of  dried  alum  (50  parts  to  -150  parts  of  the  vaselin  and  paraf- 
fin base,  page  62),  Peruvian  balsam,  ichthyol,  and  carbolic  acid  in  proper 
proportion  should  be  used. 


FURUNCLE,  CARBUNCLE,  ANTHRAX,  AND  GLANDERS 
Furuncle. — A  furuncle  or  boil  is  a  circumscribed  inflammation  of  the 
skin,  characterized  by  a  typic  course.  It  is  caused  by  a  coccus,  probably 
Staphylococcus  pyogenes  aureus,  which  reaches  the  roots  of  the  hair  by  pene- 
trating along  the  sheaths  of  the  hair-follicles  from  the  deep  epidermal  layer. 
Its  appearance  is,  therefore,  restricted  to  regions  in  which  hair  grows,  and 
it  attacks  by  preference  those  portions  of  the  bod}'  that  are  particularly  ex- 
posed. Certain  anatomic  peculiarities  will  likewise  predispose  to  the  pro- 
duction of  these  cocci.  In  some  indi^'iduals  the  openings  of  the  sheaths  of 
the  hair-follicles  are  larger  than  in  others,  and  in  certain  portions  of 
the  body  the  same  difference  exists.  If  the  cocci  do  not  penetrate  be- 
yond the  mouth  of  the  follicle,  only  a  pustule  is  formed.  In  the  majority 
of  cases,  if  they  pass  beyond  the  mouth  of  the  foUicle,  a  true  furuncle  results. 
Inder  these  circumstances  a  violent  inflammation  follows,  characterized  by 
necrosis  of  the  hair-follicle  and  the  surrounding  connective  tissue.  A  cir- 
cumscribed red  swelling  of  the  skin  appears,  the  center  of  which  is  occupied 
by  the  affected  hair-follicle.  A  varying  amount  of  necrosis  follows,  and  con- 
stitutes what  is  known  as  the  core.     A  furuncle  may  occasionahv  invade  the 


78  INJURIES    AND    DISEASES    OF    SEPARATE   TISSUES 

subcutaneous  cellular  tissue,  in  which  case  a  phlegmonous  inflammation  may 
result. 

Carbuncle. — A  carbuncle  is  a  circumscribed  inflammation  of  the  skin 
occupying  a  larger  area  than  the  boil  or  funmcle,  and  results  from  the  ex- 
tension of  infection  from  one  hair-follicle  to  a  number  of  others  in  the  neigh- 
borhood. Or  it  may,  after  commencing  as  a  comparatively  superficial  in- 
flammation, extend  to  the  subcutaneous  connective  tissue.  It  more  com- 
monly attacks  the  thick  skin  at  the  back  of  the  neck  and  in  tlie  upper 
dorsal  region,  in  ^^'hich  regions  the  hair-follicles  are  arranged  in  groups  and 
their  sheaths  pass  deeply  into  the  subcutaneous  connective  tissue.  The  rigid 
connective-tissue  fibers  in  these  regions  so  interfere  with  the  circulation  on 
the  access  of  inflammation  that  a  venous  stasis  occurs.  This  gives  to  the 
swelling  a  bluish  tint.  The  sloughing  process  begins  in  the  subcutaneous 
connective  tissue  and  extends  thence  to  the  surface,  the  latter  breaking  doAATi 
at  several  points  at  once  and  giving  the  mass  a  honeycombed  appearance. 
The  gluteal  region  may  be  attacked  b}-  carbuncle.  Ilere  the  extension  may 
be  considerable  in  the  fatty  solid  connective  tissue  of  the  part,  and  large 
fiat  swellings  may  occupy  comparatively  large  areas  without  producing  a 
proportionate  amount  of  elevation  of  the  surface.  Sloughy  masses  of  con- 
nective tissue  of  considerable  size  are  present  in  carbuncle  in  this  region. 

In  the  cou.rse  of  diabetes  mellitus  carbuncles  are  liable  to  appear.  A 
reasonable  explanation  for  the  frequent  combination  of  diabetes  and  carbuncle 
has  not  as  yet  been  found.  Under  these  circumstances  carbuncle  not 
infrec[uently  proves  fatal.  Carbuncle  may  likewise  threaten  life  in  compar- 
atively healthy  persons  who  have  no  general  disease.  The  prognosis  is  graver 
when  it  occurs  in  elderly  people,  and  likewise  when  erysipelas  or  phlegmon 
arises  as  a  complication.  Death  may  occur  from  phlebitis  and  septic 
emboli  (pyemia),  or  from  exhaustion  or  septic  pneumonia. 

Anthrax. — The  occurrence  of  a  carbuncular  process  about  the  lips, 
cheeks,  and  forearms  or  dorsum  of  the  hands  should  at  once  excite  suspicion 
of  anthrax,  a  disease  originating  in  oxen  and  sheep,  and  especially  liable  to 
occur  in  those  handling  the  dried  hides  of  these  animals.  This  suspicion 
will  be  strengthened  if  the  gangrenous  process  forms  and  spreads  rai^idly. 
An  examination  of  the  affected  tissue,  if  this  disease  is  present,  will  reveal 
the  presence  of  the  anthrax  bacillus  (see  page  30). 

Glanders. — This  is  a  contagious  disease  occurring  primarily  in  horses 
or  in  asses  and  mules.  It  is  characterized  in  these  animals  by  an  ulceration 
of  the  mucous  membrane  of  the  nose,  swelling  of  the  submaxillarv  glands, 
and  suppurati^'e  metastases  in  internal  organs.  It  is  capable  of  being  trans- 
mitted to  certain  other  of  the  lower  animals,  and  to  man  as  well.  The  in- 
fection usually  takes  place  through  some  small  abrasion,  though  this  may 
occur  through  the  hair-follicles.  At  the  point  of  entrance  of  infection  there 
appear  small  ulcers  with  sharp  edges,  which  secrete  a  thin  pus.  These  may 
be  on  any  point  of  the  skin  usually  exposed,  or  on  the  mucous  mem- 
brane of  the  nose  or  on  the  conjunctiva.  Extensive  inflammation  of  the 
superficial  structures  first  attacked,  together  with  inflammation  of  the  under- 
lying connective  tissue,  results.  This  inflammation  may  follow  the  course  of 
the  lymph-channels.  Pustules  or  nodules  appear,  whicli  break  doAATi  into 
ulceration  and  discharge  pus;  more  or  less  extensive  abscesses  may  follow,  and 


SKIN    AND    SUBCUTANEOUS    CONNl-XTIVE  TISSUE  79 

large  vesicles  coiuaiiiing-  thick  imicus-like  pus  may  form.  These  vesicles  and 
pustules,  on  discharging,  break  down  w  ith  a  tendency  to  phagedena,  and  are 
characteristic  of  the  disease;  they  mark  the  occurrence  of  general  infection. 
Similar  lesions  may  occur  in  the  respiratory  passages,  muscles,  etc.  l^ven 
the  bones  and  joints  may  become  iuA-olved.  The  specific  microorganism 
(Bacillus  mallei)  somewhat  reseml^les  the  Bacillus  tuberculosis.  It  is  some- 
times found  in  the  blood,  but  oftener  in  the  foci  formed  by  the  nodules. 

The  Treatment  of  Furuncle,  Carbuncle,  Anthrax,  and  Glanders.— 
In  tlie  treatment  of  furuncle  early  and  free  incision  is  of  the  first  importance. 
This  permits  antiseptic  applications  to  the  parts,  particularly  if  followed  at 
once  by  the  use  of  the  sharp  spoon  or  curet  in  those  cases  in  which  necrosis 
has  occurred.  The  application  of  a  5  per  cent  solution  of  carbolic  acid  or 
of  a  1  :  1000  sublimate  solution  at  once  arrests  the  infection.  Warm  com- 
presses of  either  of  these  solutions,  covered  with  either  oiled  silk  or  rubber  tissue, 
are  of  service.  If  pointing  has  already  occurred,  free  incision,  followed  by 
curetting  and  packing  ^^dth  gauze  wet  mth  the  subhmate  solution,  and  covered 
with  the  wet  compress  and  impermeable  covering,  is  an  admirable  measure 
and  calculated  to  afford  immediate  relief. 

In  carbuncle  a  most  vigorous  course  must  be  pursued  from  the  ver}^ 
start  in  order  to  limit  the  infection  and  resulting  slough  as  much  as  possible. 
A  number  of  parallel  incisions  or  free  crucial  incisions  are  to  be  made,  or, 
better  still,  complete  excision  of  the  underlymg  mass  practised,  the  four  cor- 
ners of  the  skm  resulting  from  the  crucial  incision  of  the  older  authors  being 
turned  back  in  four  flaps  for  this  purpose  (Riedel).  By  this  means  a 
dangerous  inflammatory  focus  is  removed,  the  local  and  general  infection  is 
arrested  in  its  progress,  and  rapid  healing  follows.  The  resulting  cavity 
is  to  be  treated  with  pure  carbohc  acid,  which,  after  the  lapse  of  two  minutes, 
is  washed  away  with  alcohol,  and  a  packing  or  tampon  of  iodoform  or  sub- 
limate gauze  apphed.  A  w^et  compress  of  the  latter,  and  a  covermg  of  im- 
permeable material,  as  in  the  case  of  the  furuncle,  complete  the  dressing. 
A  50  per  cent  solution  of  zinc  chlorid  may  be  used  in  place  of  the  carbolic 
acid,  and  gauze  vrcung  out  of  a  25  per  cent  solution  of  the  latter  in  glycerm 
used  as  a  dressing  until  the  infection  is  arrested.  Ordinary  stimulating 'dress- 
ings T^nll  then  suffice. 

In  carbuncles  arising  from  anthrax  infection  the  same  vigorous  meas- 
ures are  employed.  The  thermocautery  of  Paquelin,  how^ever,  should  be 
substituted  for  the  carboUc  acid  or  zinc  chlorid  application  following  either 
crucial  incision  or  extirpation. 

A^  similar  energetic  procedure  is  indicated  in  glanders.  The  bacillus 
of  this  disease  is  readily  killed  by  the  application  of  heat,  as  well  as  by  the 
sul^hmate  solution. 

GRANULAR  INFLAHHATION  OF  THE  SKIN  AND  SUBCUTANEOUS 
CONNECinrE  TISSUE 

Tuberculosis  of  the  Skin.- This  is  by  far  the  most  common  form  of 
granular  inflammation  of  the  skin.  It  may  appear  in  the  form  of  (1)  lupus; 
(2)  tuberculous  ulcer;    (3)  the  so-called  cadaver  or  anatomic  tubercle. 

Lupus  was  formerly  classed  among  the  scrofulous  diseases.     In   1874  it 


80  INJURIES    AND    DISEASES    OF    SEPARATE   TISSUES 

was  suggested  that  it  was  a  local  tuberculosis  (Volkmann,  Fried- 
lander).  Soon  after  Koch's  discovery  of  the  Bacillus  tuberculosis  this 
microorganism  was  demonstrated  in  lupus.  It  is  not  always  easy,  however, 
to  identify  the  microorganism.  The  disease  attacks  by  preference  young 
adults,  though  it  may  attack  those  in  advanced  years.  It  most  frequently 
affects  the  skin  of  the  face.  Rarely  it  is  found  on  the  mucous  membranes. 
Generally,  when  present  on  the  latter  structure,  it  advances  from  the  direc- 
tion of  the  skin.  Occasionally  it  is  seen  on  the  hand,  forearm,  arm, 
and  breast.  It  may  appear  in  more  than  one  place  in  the  same  individual. 
The  disease  was  formerly  classed  among  the  tumors,  but  its  inflammatory 
character  is  manifest  from  the  suppurative  and  ulcerative  destruction  of  the 
granular  masses.  The  tendency  of  the  disease  is  to  remain  local;  rarely, 
however,  it  may  lead  to  general  tuberculosis.  The  variety  known  as  lupus 
vulgaris  is  most  frequently  seen  on  some  portion  of  the  nose  or  eyelids. 
The  course  of  the  inflammation  is  essentially  chronic,  making  its  fii'st  appear- 
ance as  brownish-red  nodules  which  break  down  into  ulceration  and  slowl}' 
coalesce.  In  the  nose  and  eyelids  the  cartilages  may  become  involved,  and 
the  nasal  bony  structure  as  well.  As  long  as  the  skin  structure  alone  is 
attacked  there  is  a  tendency  on  the  part  of  the  ulcerated  surface  to  cicatrize, 
while  at  the  same  time  in  one  or  another  direction  fresh  nodules  make  their 
appearance,  which  in  their  turn  pass  through  the  same  processes.  In  this 
way  a  considerable  area  may  become  involved,  in  some  portions  showing 
the  whitish  scar  tissue,  in  others  the  elevated  nodules,  while  in  others,  again, 
an  ulcerative  destruction  is  in  progress.  The  cicatrized  surface  is  frequently 
covered  with  scales  of  thickened  epidermis  which  repeatedly  exfoliate.  When 
the  ulcerative  process  extends  beyond  the  thickness  of  the  skin  and  proceeds 
more  rapidly  than  cicatrization,  the  disease  is  known  as  lupus  exedens.  In 
cases  in  which  the  granular  proliferation  is  a  marked  feature,  it  is  known  as 
lupus  hypertrophicus.  The  variety  characterized  by  scaling  of  the  epider- 
mal layer  is  known  as  lupus  exfoliatus.  All  three  varieties  may  be  present 
in  the  same  individual. 

The  differential  diagnosis  of  lupus  and  carcinoma  of  the  skin  is  made 
by  attention  to  the  following  points:  (1)  the  peculiar  condition  of  the  ulcerated 
border  and  the  nodules  at  and  beyond  this;  (2)  the  tendency  on  the  part  of  lupus 
to  cicatrize  in  one  portion,  while  fresh  nodules  break  down  in  others,  as 
compared,  in  carcinoma,  with  the  progressive  tendency  to  spread  in  all  direc- 
tions. Some  difficulty  may  arise  in  cases  in  which  carcinoma  develops  at 
the  site  of  an  old  lupus.  This  occurs  rarely  on  the  face,  but  may  take 
place  on  the  dorsum  of  the  foot  or  hand.  Lymphatic  involvement  may 
be  present  in  either  disease.  Lupus  exfoliatus  may  at  first  glance  resemble 
a  dry  eczema,  but  it  is  to  be  differentiated  from  the  latter  by  the  fact  that  in 
lupus  the  scaly  formation  is  formed  on  cicatricial  tissue,  while  in  eczema 
there  is  no  cicatricial  formation. 

The  prognosis  of  lupus  will  depend  on  the  extent  of  the  surface  in- 
volvement and  the  depth  to  which  it  penetrates.  As  before  stated,  it  rarely 
gives  rise  to  general  tuberculosis,  though  this  danger  is  not  to  be  lost  sight 
of.  The  functional  prognosis,  however,  is  important;  extensive  and  extreme 
deformities  may  result  from  its  presence,  equaled  only  by  the  cicatricial  shrink- 
ing resulting  from  burns. 


SKIX    AND    SUBCUTANEOUS    CONNECTIVE   TISSUE  81 

The  treatment  of  lupus,  owing  to  the  fact  that  the  disease  de]:)ends  on  a 
specific  bacilhis,  will  be,  as  far  as  possible,  in  the  line  of  radical  measures 
to  effect  its  complete  destruction  and  removal.  This  is  accomplished  by 
means  of  the  sharp  spoon.  The  entire  area  involved  is  thoroughly  scraped 
and  stimulating  applications  employed  in  the  after-treatment.  A  more 
satisfactory  method,  however,  consists  in  total  excision  of  the  diseased  area 
and  the  subse^iuent  transplantation  of  strips  of  skin  after  the  method  of 
Thiersch  (Senger).  This,  together  with  rhinoplastic  and  cheilo- 
plastic  procedures,  ^^ill  be  described  in  connection  with  special  operative 
procedures.  The  use  of  the  thermocautery  and  gah'anocautery  has  been 
advocated;  the  influence  of  heat,  as  in  certain  galvanocautery  operations 
about  the  uterus  (John  Byrne),  is  believed  to  extend  beyond  the  area 
of  the  part  to  which  the  cautery  iron  is  actually  applied,  destro^-ing  in  the 
neighboring  tissues  the  noxious  agents  which  produce  the  disease.  The  use 
of  the  .r-ray,  as  well  as  of  Finsen's  light,  has  proved  effective  in  lupus  and 
in  the  superficial  carcinoma  for  which  it  may  be  mistaken.  These  are  like- 
wise recommended  to  prevent  recurrence  after  radical  operations  for  the 
cure  of  these  conditions. 

Certain  chemic  corrosive  substances,  such  as  the  zinc  chlorid  (10  to  20 
per  cent),  may  be  useful  in  certain  cases.  Nitrate  of  silver  is  too  superficial 
in  its  effects,  and  tincture  of  iodin,  sometimes  recommended,  is  applicable 
only  to  the  most  superficial  varieties  of  the  affection.  The  application  of 
caustic  alkalis,  such  as  caustic  potash,  is  to  be  deprecated  for  the  reason  that 
the  resulting  slough  is  moist  in  character,  and  hence  forms  a  putrefying  mass 
in  which  microorganisms  proliferate  and  extend  into  the  surrounding  struc- 
tures, producing  violent  inflammation.  The  use  of  chlorid  of  zinc,  carbolic 
acid,  nitric  acid,  etc.,  by  coagulating  the  albuminates,  produces  a  dr\"  eschar 
which  is  more  easily  maintained  aseptic.  This  point  may  be  borne  in  mind 
Adth  advantage  in  the  application  of  caustics  in  affections  other  than  lupus. 

Tuberculous  ulcer  is  the  result  of  a  breaking  down  of  a  tuberculous 
gumma.  The  latter  affects  primarily  the  subcutaneous  connective  tissue. 
The  neck,  chest,  and  extremities  are  favorite  locations  for  its  appearance. 
The  gumma  consists  of  a  painless  swelling  of  varying  sizes,  which  pursues 
a  chronic  inflammatory  course  and  shows  constant  tendency  both  to  form 
granulation  tissue  and  to  break  down  easily  into  ulceration.  The  involve- 
ment of  the  integument  gives  this  a  bluish  or  a  reddish  tint  just  prior  to 
ulceration.  When  this  takes  place,  one  or  more  small  openings  may  lead  down 
to  the  mass  of  granulation  tissue  beneath.  The  skin  structure  is  loosened 
from  the  latter  by  a  process  of  suppurative  inflammation,  and  the  ulcer  pre- 
sents one  or  more  openings  in  the  skin,  T\'ith  overhanging,  thin,  livid  edges. 
"\Mien  these  openings  are  enlarged,  there  may  be  seen  througli  them  the 
irregiflar  surface  of  the  mass  of  granulation  tissue  beneath,  presenting  the 
classic  picture  of  a  tuberculous  ulcer.  This  may  occur  at  the  site  of  a  lym- 
phatic gland,  in  which  case  it  is  difficult  to  decide  whether  the  gland  or  the  skin 
and  the  underlying  structure  were  the  site  of  the  primary'  infection.  The 
affection  may  be  associated  Avith  tuberculosis  elsewhere.  The  treatment 
consists  in  dissecting  away  the  overh'ing  skin,  in  curetting  the  granulation 
tissue,  and  in  applying  vigorously  to  the  surface  zinc  chlorid  in  10  per 
cent    solution    (L  a  n  n  e  1  o  n  g  u  e) .     Camphorated   naphthol  (P  e  r  r  i  e  r)  is 


82  INJURIES   AND   DISEASES   OF   SEPARATE  TISSUES 

strongly  recommended  as  an  antituberciilotic  agent,  as  well  as  iodoform 
(Billroth,  Mikulicz),  and  Peruvian  balsam  and  cinnamic  acid 
(L  a  n  d  e  r  e  r). 

The  so-called  cadaver  tubercle,  or  anatomic  tubercle,  is  a  granular 
inflammation  occurring  as  a  flattened  nodule  on  the  backs  of  the  fingers  and 
hands  of  anatomists  and  their  assistants,  and  is  now  recognized  as  a  distinctly 
tuberculous  affection,  though  some  doubt  is  still  expressed  as  to  its  exclu- 
sive origin  from  tuberculous  infection.  Other  agents,  particularly  ptomains, 
give  rise  to  similar  nodules.  They  resemble  plaques  of  lupus  hypertrophicus, 
and  vary  in  size  from  a  pea  to  an  almond.  They  may  occur  in  clusters  or 
singly,  and  their  favorite  site  is  the  dorsal  surface  of  the  metacarpopha- 
langeal joints.  Erythematous  patches  and  pustules  may  likewise  appear. 
Though  cadaver  tubercle  rarely  becomes  purulent,  and  scarcely  ever  gives 
rise  to  extensive  inflammation  of  the  connective  tissue  and  of  the  lymph- 
channels  and  glands,  yet  the  nodule  should  be  thoroughly  removed,  either  by 
excision  or  by  application  of  the  thermocautery. 

Syphilis  of  the  Skin. — From -the  viewpoint  of  the  general  surgeon, 
the  two  most  important  lesions  of  the  skin  occurring  as  the  result  of  syphilis 
are  (1)  the  syphihtic  initial  sclerosis  ;  (2)  the  syphilitic  gumma  of  the  sub- 
cutaneous connective  tissue.  The  initial  lesion  of  syphilis,  as  its  name  im- 
plies, is  the  first  manifestation  of  the  presence  of  the  disease,  as  far  as  is  at 
present  knoAAOi.  It  occurs  at  the  point  where  the  infection  makes  its  entrance, 
and  occupies  from  ten  to  thirty  days  in  its  development  after  the  date 
of  infection.  The  sclerotic  nodule,  when  first  noticed,  is  usually  about  the 
size  of  a  pea.  The  center  of  the  infiltrated  part  breaks  down  into  an  ulcer, 
the  edges  of  which,  as  well  as  the  base,  being  formed  of  granulation  material, 
retain  their  characteristic  hardness.  This  constitutes  the  classic  so-called 
Hunterian  or  hard  chancre.  It  may  happen  that  a  soft  chancre,  or  non- 
syphilitic  venereal  sore  (chancroid),  resulting  from  contact  with  indifferent 
or  not  necessarily  specific  organisms,  may  follow  within  a  day  or  two  after 
exposure,  which,  pursuing  the  course  of  such  ulcer  ujd  to  a  certain  point,  may 
thereafter  present  the  symptoms  of  genuine  syphilitic  chancre.  Here  the 
syphilitic  local  infection  follows  the  usual  course  of  incubation  of  from  ten 
to  thirty  days,  the  indifferent  or  nonspecific  infection  producing  its  local 
effect  at  once.  It  may  happen,  on  the  other  hand,  that  a  primary  sclerosis 
may  occur,  which  never  breaks  down  into  ulceration,  but,  after  running  its 
course  as  a  granulating  infiltration,  disappears. 

The  location  of  the  initial  sclerosis  varies,  but,  as  a  rule,  it  occurs  on  the 
genitals.  Exceptionally,  it  has  been  found  witliin  the  oral  cavity,  on  the 
tonsils,  and  on  the  end  of  the  nose.  Nonvenereal  syphilitic  chancre  may 
occur  on  the  surgeon's  fingers  from  abrasions  arising  from  contact  with  the 
ulcerated  initial  sclerosis,  or  the  lymph  or  blood  of  infected  patients.  The 
site  of  vaccination  is  likewise  occasionally  the  seat  of  a  syphilitic  chancre,  and 
the  infection  has  been  conveyed  in  ritualistic  circumcision,  .the  source  of  the 
contagion  here  being  mucous  patches  in  the  mouth  of  the  operator,  it  being 
customary  to  place  the  infant's  penis  therein  after  the  operation.  Vaccino- 
syphilis  can  occur  only  when  blood  from  a  syphilitic  subject  is  transmitted 
along  with  the  vaccine  virus. 

The  gummas  of  the  skin  and  subcutaneous  connective  tissue  resemble 


SKIN   AND    SUBCUTANKOUS   CONNECTIVE   TISSUE  83 

closely  at  first  glance  the  initial  infiltration  at  the  point  of  infection.  The 
latter,  however,  will  be  found  to  occupy  the  tissue  of  the  skin  almost  exclusively, 
while  the  former  may  or  may  not  invade  the  deeper  structures.  The  gummas 
of  the  skin  generally  appear  as  a  late  manifestation  of  the  disease.  They  may 
disappear  by  absorption  without  ulceration,  or  they  may  break  down  into 
ulceration,  and  by  fusion  with  several  in  the  immediate  neighborhood  form  a 
spreading  and  creeping  ulceration  (serpiginous  ulcer).  The  gummas  extend- 
ing into  the  subcutaneous  connective  tissue  or  originating  in  it  are  liable  to 
occur  as  large  infiltrated  areas,  but  undergo  the  same  changes.  Gummas 
of  the  skin  and  subcutaneous  connective  tissue  affect  particularly  the  forehead, 
neck,  shoulders,  and  legs,  named  in  the  order  of  frequency  of  occurrence  of 
the  gummas. 

The  treatment  of  a  sore  suspected  to  be  the  initial  sclerosis  of  syphilis 
should  be  purely  local.  Under  no  circumstances  should  the  practitioner  be 
induced  to  treat  constitutionally  what  may  not  prove  to  be  a  genuine  syphilitic 
infection  on  the  chance  of  its  being  such.  By  so  doing  he  robs  the  patient 
of  the  only  means  of  knowing  whether  or  not  he  really  has  syphilis,  b}^  pre- 
venting the  occurrence  of  the  secondary  S3^philitic  skin  lesions,  which  are 
decisively  diagnostic  and  final.  The  prevention  of  the  occurrence  of  these 
does  no  real  good,  inasmuch  as  no  harm  can  arise  from  their  presence.  Early 
excision  has  been  practised  with  the  vieAV  of  pre^^enting  the  constitutional 
de^-elopment  of  the  disease,  and  some  success  has  been  claimed  for  this.  In 
cases  of  supposed  arrest  of  the  disease  by  excision  conclusive  evidence  that 
the  disease  ever  existed  is,  of  course,  wanting.  Then,  too,  the  long  delay  in 
the  appearance  of  the  local  lesion  suggests  that  the  primaiy  sore  is  really  only 
the  local  expression  of  a  constitutional  infection  which  has  been  undergoing 
a  process  of  incubation  in  the  interval.  Such  considerations  have  impaired 
the  confidence  of  surgeons  in  primary  excision  of  chancre  for  the  prevention 
of  syphilis.  Therefore,  in  the  treatment  of  chancre  simple  antiseptic  dusting- 
powders,  or  some  form  of  antiseptic  dressing  fulfil  all  the  indications. 

Gummas  of  the  skin  and  subcutaneous  connective  tissues  occur  among 
late  lesions  of  the  disease,  and  are  to  be  treated  on  general  antisyphilitic 
principles.  In  case  ulceration  takes  place,  excision  or  curetment  is  indicated, 
generally  the  latter.  This  is  to  be  followed  by  the  application  of  zinc  chlorid 
in  a  10  per  cent  solution,  with  after-dressings  of  sublimate  moist  gauze. 

Leprosy. — When  Bacillus  leprae  invades  the  body,  it  manifests  its  pres- 
ence in  a  variety  of  ways.  Early  in  the  disease,  months,  and  it  is  said  years, 
sometimes  elapse  before  the  appearance  of  local  manifestations.  In  the  mean- 
while the  patient  suffers  from  general  malaise,  languor,  chills,  fever,  and  osteo- 
copic  pains.  The  most  prominent  of  the  local  symptoms  are  the  lesions  of 
the  skin.  These  may  be  bullae,  maculae,  or  tubercles.  Based  on  these  different 
manifestations,  varieties  of  the  disease  have  been  described,  such  as  tubercular, 
macular,  etc.  As  all  these  lesions  may,  and  usually  do,  appear  in  the  same 
patient,  there  seems  to  be  no  good  reason  for  making  such  distinctions.  As  a 
matter  of  fact,  the  first  cutaneous  manifestation  of  the  disease  is  the  appear- 
ance of  bullae.  As  the  deeper  cutaneous  structures  become  involved,  maculae 
develop,  of  a  red  color  at  first  (the  lepra  rubra  of  some  authors),  this  fading 
later  into  a  brownish  hue.  With  the  appearance  of  the  maculae,  symptoms 
of  peripheral  nervous  disturbances  show  themselves,  first,  as  hyperesthesia 


84  INJURIES    AND    DISEASES    OF   SEPARATE   TISSUES 

from  irritation,  and,  second,  as  anesthesia  from  loss  of  function.  As  the  disease 
advances,  tubercles  make  their  appearance  on  all  parts  of  the  body,  most  numer- 
ous, however,  on  the  more  exposed  regions.  These  ma}'  or  ma}-  not  ulcerate, 
though  they  usually  do.  With  the  invasion  of  deeper  structures,  such  as  the  sub- 
cutaneous cellular  tissue,  the  muscles  or  bones,  atrophy  may  take  place,  and, 
as  the  bones  and  joints  are  attacked,  the  fingers  and  toes  drop  off.  Clreater 
mutilations  may  occur,  even  to  the  loss  of  hands  and  feet.  In  the  skin 
of  the  face  a  peculiar  hypertrophy  with  wrinkling  takes  place,  gi^■ing  rise  to 
the  peculiar  facial  appearance  called  leontiasis.  These  different  lesions  do 
not  make  their  appearance  in  any  regular  order.  They  may  exist  together. 
The  tubercles  may  predominate,  in  which  case  we  have  the  so-called  tubercular 
leprosy;  or  maculae  and  general  anesthesia  may  be  the  characteristic  features, 
in  which  case  we  have  the  anesthetic  leprosy  of  some  writers.  It  is  evident 
that  the  disease  is  the  same  in  all  cases,  and  that  the  varieties  which  have 
been  described  depend  really  on  the  structure  attacked  by  the  bacillus, 
which  is  in  every'  case  identical.  This  disease  is  not  to  be  confounded  with 
elephantiasis  Arabum. 

The  prognosis  of  leprosy  is  exceedingly  grave.  It  is  essentially  an  in- 
curable disease.  The  victim  usually  perishes  of  exhaustion,  or  of  some  second- 
ary wound  disease,  such  as  tetanus. 

There  is  a  disease  common  to  tropical  climates  called  elephantiasis  Ara= 
bum,  or,  from  the  frequency  with  which  it  is  seen  in  the  West  Indies,  Bar- 
badoes  leg.  It  is  not  to  be  confounded  with  elephantiasis  Graecorum,  or 
leprosy,  to  which  it  is  in  no  respect  akin.  It  may  attack  any  part  of  the 
body,  but  in  the  great  majority  of  cases  the  lower  extremities  are  the  seat 
of  the  disease;  next  in  frequency  the  genitalia,  more  especially  the  scrotum 
in  the  male  and  the  labia  majora  in  the  female,  are  attacked.  The  disease 
is  characterized  by  great  hypertrophy  of  the  skin  and  subcutaneous  tissue. 
The  sldn  itself  becomes  fissured,  roughened,  and  edematous,  and  hangs  in 
enormous  folds,  giving  to  the  limbs,  when  the  disease  occurs  there,  the  ap- 
pearance of  elephant  legs.  The  hypertrophy  is  very  great,  so  that  a  scrotum 
the  seat  of  the  disease  has  been  known  to  weigh  a  hundred  pounds.  It  com- 
mences like  an  erysipelatous  inflammation,  but  constantly  recurs,  each  attack 
leaving  more  and  more  thickening  of  the  tissues.  It  is  supposed  to  be  due 
to  obstruction  of  the  lymphatics  of  the  part,  though  the  etiology  of  the 
disease  is  still  obscure.  In  very  numerous  cases  Filaria  sanguinis  hominis 
has  been  discovered  in  the  blood,  and  to  this  parasite  have  been  attributed 
the  origin  of  the  obstruction  and  the  inflammatory  lymphangitis  which  is 
uniformly  present.  Operative  procedure  offers  the  only  hope  of  relief  from 
the  disease.  When  it  occurs  in  the  penis  and  scrotum,  early  amputation  is 
largely  successful.  When  the  disease  has  appeared  in  an  extremity,  liga- 
tion of  the  femoral  artery  has  been  practised,  with  much  less  success,  how- 
ever. The  immediate  result  of  the  operation  has  been  a  prompt  diminution 
of  the  size  of  the  limb,  but  unfortunately  improveinent  has  been  but  tem- 
porary. In  early  cases  ligation  of  the  external  iliac  artery  gives  better 
results  (Hueter).  Digital  compression  has  been  tried  with  some  benefit, 
but  early  amputation  offers  the  best  hope  of  permanent  reUef. 


INJURIES    AND    DISEASES   OF   BLOOD-VESSELS  85 


INJURIES  AND  DISEASES  OF  BLOOD-VESSELS 

INJURIES   OF   ARTERIES 

In  severe  crush  injuries  to  the  limbs  the  vessels  are  ruptur(Ml  or  torn  across, 
and  in  machinery  accidents  they  are  frequently  twisted.  Under  these  cir- 
cumstances the  bleeding  is  comparatively  slight.  This  is  due  to  the  fact  that 
the  internal  and  middle  coats  are  more  easily  torn  than  the  outer,  and  give 
wa}'  first,  thus  occluding  the  lumen  of  the  vessel.  The  occlusion  results 
from  the  rolhng  in  of  the  middle  coat  or  the  retraction  of  it,  and  occurs  in  the 
fraction  of  a  second.  In  case  of  a  crush  injury  the  adventitia  or  external  coat 
is  forced  about  the  retracted  ends  of  the  middle  coat;  in  case  of  a  machinery 
accident,  the  member  is  usually  forcibly  twisted,  and  therefore  torsion  of 
the  external  coat  still  further  supports  the  retracted  ends  of  the  internal 
and  middle  coats.  Further,  the  elastic  middle  coat  sends  prolongations  of 
its  elastic  fibers  into  the  closely  woven  network  of  connective  tissue  which 
constitutes  the  external  coat  (B  a  11  a  n  c  e  and  Edmunds),  so  that  a 
retraction  of  the  middle  coat  involves  some  retraction  of  the  external  coat 
as  well.  The  middle  coat  will  likewise  vary  according  to  the  age  of  the 
individual,  and  differences  will  be  noticed  in  different  portions  of  the 
same  body ;  consequently,  the  facihty  with  which  the  retracted  middle  coat 
closes  the  lumen  of  the  vessel  will  vary. 

Contusion  of  the  artery  is  sometimes  occasioned  by  the  striking  and 
glancing  off  of  a  bullet  or  other  missile.  The  artery,  unless  held  firmly  in 
position  against  a  bony  surface  by  overlying  structures,  will  be  pushed  aside, 
though  bruised  by  the  contact.  Under  these  circumstances  the  injury  to 
tissue  may  be  so  great  as  to  cause  rupture  of  the  vessel  and  so-called  second- 
ary hemorrhage  {vide  infra).  The  catastrophe  from  this  cause  may  be  ex- 
pected in  from  eight  to  ten  days  after  the  injury.  In  other  instances  the 
supposed  contusion  turns  out  to  be  really  a  partial  rupture  of  the  artery,  a 
portion  of  the  intima  giving  way,  this  curling  up  and  producing  occlusion 
more  or  less  permanent  at  this  point.  Gangrene  of  an  extremity  may  occur 
as  the  result  of  complete  or  partial  rupture  or  contusion.  In  case  of  partial 
rupture  the  thrombus  which  is  formed  is  of  irregular  shape.  This  irregularity 
in  shape  leads  to  a  further  fibrinous  deposit,  and,  as  this  occurs  eventy  and 
follows  the  shape  of  the  original  thrombus  as  a  mold,  it  happens  that  the 
latter  is  continued  almost  indefinitely,  in  time  occluding  the  entire  trunk 
and  its  collateral  branches.  Thus  the  blood-supply  of  the  part  is  cut  off  and 
more  or  less  extensive  gangrene  results. 

Gunshot  Injuries  of  Blood=vessels. — The  proportion  of  injuries  of  large 
vessels,  or  those  requiring  the  application  of  a  ligature,  to  the  total  number 
of  wounds  received  in  battle,  exclusive  of  those  which  prove  immediately 
fatal  from  hemorrhage,  is  astonishingly  small.  This  is  the  more  surprising 
in  view  of  the  fact  that,  in  the  case  of  the  old-fashioned  unprotected  spheric 
leaden  missile,  the  smashing  of  bone,  the  splitting  of  the  projectile  into  frag- 
ments, and  the  deformation  of  the  bullet  greatly  contributed  to  increase 
the  chances  of  injury  of  neighboring  blood-vessels.  The  liability  to  the  wound- 
ing of  blood-vessels  in  this  manner  is  lessened  in  the  case  of  the  modern  high- 


86  IXJURIES    AND    DISEASES    OF    SEPARATE   TISSUES 

velocity  and  mantled  projectile,  the  smaller  size  likewise  contributing  to  the 
escape  of  the  vessels.  On  the  other  hand,  however,  the  high  velocity,  pointed 
form,  and  direct  course  of  the  projectile  through  the  tissues  increase  the  chances 
of  direct  injury  to  the  vessels  in  its  path. 

Death  from  external  primar}^  hemorrhage  is  very  rare;  the  same  may  be 
said  of  the  necessity  for  immediate  ligation  of  a  large  vessel.  Recurrent  and 
secondar}^  hemorrhages  when  caused  by  the  modern  projectiles  are  likewise 
uncommon,  though  the}'  take  place  with  sufficient  frequency  to  keep  the  sur- 
geon alert  as  to  the  possil^ilities  of  their  occurrence.  Such  injuries  as  con- 
tusions or  lacerations  without  the  invasion  of  the  lumen  of  the  vessel  may  occur, 
to  be  subsequently  followed  by  ulceration  in  the  case  of  the  former,  and  b}'  com- 
plete perforation  in  the  case  of  the  latter.  The  secondary'  hemorrhage  which 
results  may  occur  in  a  few  hours,  or  it  may  be  postponed  for  from  one  to  three 
weeks.  It  is  most  likely  to  occur  in  the  presence  of  suppurative  condi- 
tions; in  fact,  the  latter  are  largely  responsible  at  the  present  day  for  the  occur- 
rence of  secondary  hemorrhage.  On  the  other  hand,  even  if  aseptic  healing 
takes  place,  various  kinds  of  aneurisms  may  occur  as  a  part  of  the  after- 
history. 

Incised  and  punctured  wounds  of  arteries  have  for  their  primary-  symp- 
toms, except  under  the  rare  circumstances  of  a  valvular  opening  in  the  OA^er- 
lying  parts,  active  and  idsible  hemorrhage  in  an  interrupted  or  per  saltum 
stream  varying  in  size  and  force  according  to  the  vessel  involved  and  the 
size  of  the  external  Avound.  The  bright  red  color  of  the  blood,  as  well  as  the 
jetting  character  of  the  stream,  will  serA'e  to  distinguish  this  from  venous 
hemorrhage. 

In  punctured  wounds,  in  which  the  wound  of  the  overlying  parts  is  such 
as  to  produce  a  valvelike  closure  of  the  external  opening,  escape  of  the  effused 
"blood  is  prevented,  and  this  may  collect  around  the  injured  arter\'.  The  pres- 
sure of  the  clot  in  case  of  small  arteries  causes  spontaneous  arrest  of  the  hemor- 
rhage, but  in  large  arteries  a  traumatic  aneurism  develops  (see  page  96). 

Lateral  wounds  of  the  arterial  wall,  as  a  rule,  produce  the  most  alarming 
hemorrhage.  This  is  more  particularly  true  when  the  wound  is  at  right  angles 
to  the  long  axis  of  the  A'essel.  Here  the  elastic  middle  coat,  the  fibers  of  which 
have  principally  a  longitudinal  direction,  retracts,  and  very  active  hemorrhage 
results  from  the  wide  gap  in  the  vessel  which  this  retraction  produces. 

Complete  transverse  separation  of  an  artery  leads  to  a  retraction  of 
the  ends  thereof,  on  account  of  the  marked  elasticity  of  the  middle  coat,  which 
produces  a  constant  tension  on  the  arterial  tube,  and  a  narrowing  of  the 
lumen,  in  addition,  by  the  action  of  the  constrictor  muscular  layer.  The 
extent  of  the  retraction  will  vary-  according  to  the  size  of  the  vessel  and  the 
thickness  of  its  middle  coat.  The  arrest  of  hemorrhage,  under  these  circum- 
stances, will  be  governed  by  these  considerations,  as  well  as  by  the  character 
of  the  tissues  AAithin  which  the  vessel  retracts.  If  these  are  large  masses  of 
muscular  tissue,  the  spontaneous  arrest  will  take  place  earlier,  while  if  they 
are  mostly  masses  of  loose  connective  tissue,  spontaneous  arrest  will  be  delayed. 
The  retraction  within  large  masses  of  muscular  tissue  tends  to  impede  free 
escape  of  the  blood,  and,  therefore,  after  the  blood  has  left  the  vessel,  coagula- 
tion is  favored.  When  the  hemorrhage  takes  place  into  loose  connective- 
tissue  planes,  the  accumulation  of  blood  here  will  cause  lateral  pressure  on  the 


IXJURIES    AXD    DISKASKS    OF    BLOOD-VESSELS  87 

tnmk  of  the  divided  vessel,  and  thus  arrest  ^vill  be  brought  about.  Finally, 
the  failing  power  of  the  heart's  action,  \\hether  from  shock  or  from  acute 
anemia,  favors  coagulation  and  lessens  or  arrests  the  hemorrhage.  In  the 
latter  condition  dea'tli  may  follow  unless  closure  of  the  wound  in  the  artery 
and  infusion  of  saline  solution  are  promptly  performed. 

Spontaneous  Arrest  of  Hemorrhage.— This,  tho\igh  it  may  appear 
to  be  complete,  is  not  to  be  relied  on  as  permanent.  In  the  case  of  the 
large  vessels,  particularly  in  the  course  of  a  few  hours,  when  the  heart's  action 
becomes  more  forcible,  the  obstructing  coagula  may  be  washed  away  by  the 
increased  flow  of  blood,  and  recurrent  hemorrhage  occur. 

The  occurrence  of  secondary  hemorrhage  depends  on  septic  inflamma- 
tory complications  in  wounds.  Arteries  which  have  been  torn  or  laterally 
contused  are  particulariy  liable  to  secondary-  hemorrhage.  Divided  and  ligated 
arteries  are  likewise  hable  to  septic  mvasion.  and  hence  to  the  same  compli- 
cations, though  not  in  the  same  degree,  as  the  foregoing.  The  damage  done 
to  contused  and  lacerated  vessels  is  much  greater  than  that  which  occurs  after 
simple  application  of  a  ligature;  hence,  the  local  vital  resistance  is  not  lowered 
to  the  same  extent  in  the  latter  case  as  in  the  former.  Should  the  w^all  of  the 
vessel  become  so  weakened  as  to  be  unable  longer  to  resist  the  force  of  the 
arterial  wave,  it  will  give  way  under  the  pressure  from  within.  Secondary 
hemorrhage  occurs  rarely  before  the  fourth  day  and  very  seldom  after  the 
twelfth.  ^Coincident ally \-ith  the  appearance  of  the  process  of  repair  as 
announced  bv  the  presence  of  healthy  granulations,  the  dangers  from  secon- 
darv  hemorrhage  disappear.  As  long  as  these  granulations  remain  in  a  healthy 
condition,  no  further  danger  from  this  source  is  to  be  feared  (see  page  88). 

Subcutaneous  Injury  of  Smaller  Vessels.— Contusions  produce  more 
or  less  tearing  of  the  smaller  vessels,  both  arteries  and  veins,  in  the  subcu- 
taneous connective  tissue.  As  the  blood  escapes  into  the  meshes  of  the  latter, 
it  coagulates  and  forms  what  is  known  as  a  hematoma.  The  more  or  less  solid 
tumor  thus  formed  will  vary  in  size  according  to  the  extent  of  the  extravasated 
blood.  A  familiar  form  oi  hematoma  is  that  found  on  the  head  of  a  new- 
bom  child,  in  which,  however,  the  blood  usually  remains  fluid  (cephalhema- 
toma) .  A  blow  upon  the  head,  causing  rupture  of  the  vessels  of  the  scalp  from 
impingement  agamst  the  skull  beneath,  sometimes  produces  extensive  hema- 
toma." The  center  of  this  is  often  found  to  be  quite  soft,  partly  because 
the  connective-tissue  fibers  at  this  point  tear,  and  partly  because  the 
central  mass  of  the  blood  remams  fluid.  This,  surrounded  by  the  more  solid 
and  elevated  margins,  may  give  the  impression  of  a  depressed  fracture  of  the 
skull,  ^^^len  the  hemorrhage  occurs  hi  otherwise  healthy  joints  as  the  result 
of  injun,',  it  is  knov^-n  as  hemarthrosis. 

The  swelling  which  follows  a  subcutaneous  injur}'  to  the  vessels  slowly  dis- 
appears, and  coincidentally  therewith  there  appears  on  the  surface  at  first  a  blue 
or  a  bluish-red  tint,  followed  later  on  by  a  greenish  and  a  yellowish  tint.  The 
disappearance  of  the  swelling  is  due  to  the  resorption  of  the  blood,  and  the 
discoloration  is  due  to  the  coloring-matter  of  the  latter.  Avhich  is  set  free  by 
the  destruction  of  the  red  blood-corpuscles  in  the  extravasated  blood  preceding 
resorption.  As  time  goes  on,  the  discolored  skhi  resumes  its  normal  appear- 
ance, the  coloring-matter  and  serum  being  taken  up  by  the  lymph-channels. 
In  the  great  majority  of  cases  resorption  of  the  extravasated  blood  takes 


88  INJURIES    AND    DISEASES    OF    SEPARATE    TISSUES 

place  without  leaving  any  trace  of  its  presence.  Occasionally,  however,  a  con- 
nective-tissue proliferation  surrounds  the  hematoma,  and  a  cyst  with  serous 
contents  is  formed.  In  still  rarer  instances  the  so-called  organization  of  the 
clot  occurs,  i.  e.,  the  surrounding  connective  tissue  in  its  proliferation  invades 
the  clot,  and  repair  takes  place  in  this  manner.  As  a  rule,  however,  resorp- 
tion, and  not  cicatrization,  constitutes  the  method  of  restoration. 

All  hematomas,  however,  do  not  follow  this  favorable  course.  Bacterial 
infection,  occurring  either  through  the  tightly  stretched  and  poorty  nourished 
skin,  or  along  the  sheaths  of  the  hair-follicles,  or  having  its  origin  in  the  blood 
itself,  may  produce  a  purulent  condition  of  the  mass.  The  suppuration  may 
then  assume  a  phlegmonous  character,  spreading  into  the  surrounding  connec- 
tive-tissue spaces  and  into  the  opened  up  lymph-channels,  or  may  become 
localized  and  slowly  point  toward  the  adjacent  surface,  according  to  the 
more  or  less  active  infectious  agency  of  the  bacteria. 

In  the  treatment  of  hematoma  two  indications  are  present:  (1)  the  pro- 
motion of  al^sorption  ;  (2)  the  prevention  of  suppuration.  The  first  is 
fulfilled  by  massage,  which  breaks  up  the  clot  and  stimulates  the  absorbents. 
Thorough  cleansing  of  the  injured  part  and  the  application  of  an  antiseptic 
moist  dressing  (sublimate,  Thiersch's,  or  a  carbolic  solution)  will 
meet  the  second  indication.  If  suppuration  has  already  occurred,  or  the  ten- 
sion is  considerable  and  massage  too  painful  to  be  borne,  free  incision  with 
antiseptic  precautions  must  be  made.  The  clot  is  to  be  turned  out,  the 
resulting  cavity  irrigated  with  sublimate  solution,  1:2000,  and  subsequently 
packed  with  sterile  gauze  wet  with  hydrogen  dioxid,  the  dressing  being  com- 
pleted by  a  wet  sublimate  compress. 

HEMORRHAGE 

This  term  is  applied  to  an  escape  of  blood  from  the  vessels.  It  is  more 
generally  applied  to  an  escape  of  blood  to  the  surface  or  into  a  cavity  of  the 
body.  The  latter  is  known  as  concealed  hemorrhage.  The  term  extrava- 
sation or  subcutaneous  hemorrhage  is  employed  to  designate  an  escape  of 
blood  into  the  subcutaneous  connective  tissue. 

Hemorrhage  may  be  divided  into  primary,  recurrent,  and  secondary. 
The  first  immediately  follows  the  reception  of  the  wound.  The  second 
follows  reaction  from  the  shock  or  injury,  and  is  due  to  the  increased  power 
of  the  circulation  either  displacing  the  coagula  which  have  formed  and  which 
held  the  bleeding  in  check,  or  forcing  the  blood  from  wounds  of  the  smaller 
vessels. 

Secondary  hemorrhage  may  be  due  to  a  contusion  or  abrasion  of  the  wall 
of  the  vessel  which  at  first  passed  unrecognized,  the  wall  subsequently  giA^ing 
way.  It  may  be  due  to  an  inefficiently  applied  ligature,  or  to  a  failure  to  apply 
a  ligature  to  the  distal  end  of  a  divided  "vessel,  w^hich  on  the  establishment 
of  the  anastomotic  circulation  furnishes  blood.  Premature  softening  of  an 
animal  ligature  may  also  give  rise  to  secondary  hemorrhage.  Disease  of  the 
walls  of  the  artery  (page  93),  septic  processes  (page  86),  as  well  as  cer- 
tain constitutional  conditions,  such  as  hematophilia,  septicemia,  pyemia, 
renal  and  hepatic  disease,  may  give  rise  to  secondary  hemorrhage  by  inter- 
fering W'ith  the  plastic  and  proliferatiA^e  changes  necessary  to  the  definite  seal- 
ing of  wounded  vessels. 


IX.TT-RIES    AND    DISKASKS    OF    CLOOD-VESSELS  89 

S}Tnptoms  of  Hemorrhage.— When  death  is  threatened  from  hemor- 
rhage, the  following  ,s\inptom8,  more  or  less  pronounced,  are  present:  (1) 
The  external  appearance  of  blood.  This  will  vary  according  to  the  size  of  the 
injured  vessel  and  the  rapidity  of  the  flow.  It  may  be  absent  altogether,  a 
sullieient  quantity  of  blood  escaping  into  one  of  the  larger  cavities  to  pro- 
duce syncope  (concealed  hemorrhage).  (2)  A  peculiar  hue  of  the  surface. 
This  is  a  combination  of  jjallor  and  lividity  due  to  the  fact  that  the  flow  of 
blood  fi-om  the  vessel,  ])articularly  an  arter}-,  lessens  the  vis  a  tergo  in  the 
peripheral  vessels,  and  a  venous  stasis  is  added  to  the  otherwise  pallid  sur- 
face. (3)  Coldness  and  a  clammy  condition  of  the  surface.  (4)  Dilatation  of 
the  pupils  and  twitching  movements  of  the  eyeballs.  (5)  Sighing  respirations 
and  diaphragmatic  breathing.  (6)  General  restlessness,  and  the  throwing 
about  of  the  extremities,  particularly  the  arms.  (7)  Involuntary  evacuation 
of  urine  and  feces.  (S)  Rapid  and  weak  pulse.  (9)  Coma;  more  rarely  con- 
vulsions. 

In  addition  to  these,  the  patient  complains  of  giddiness,  oppression  of 
breathing  with  occasional  gasping  efforts  (air  hunger),  intense  thirst,  and 
disturbances  of  vision  and  hearing. 

Death  may  occur  rapidly,  or  the  lowering  of  the  circulatory  tension  may 
give  an  opportunity  for  the  formation  of  coagula  at  the  point  of  injury;  the 
bleechng  may  then  cease.  The  patient  rallies,  but  the  increasing  power  of 
the  heart's  action  forces  away  the  clot  from  the  interior  of  the  injured  vessel, 
and  the  patient  relapses  into  his  former  condition.  This  may  be  repeated 
several  times  until  fatal  anemia  of  the  important  nerve-centers  occurs. 

The  rapidit}^  with  which  the  symptoms  of  hemorrhage  supervene  varies 
in  different  individuals,  and  at  different  periods  of  hfe.  A  very  small  loss  of 
blood  ma}'  produce  fatal  s}-ncope  in  weak  or  nervous  individuals;  on  the  other 
hand,  robust  or  phlegmatic  persons  may  suffer  a  considerable  loss  without 
showing  pronounced  symptoms.  The  more  rapid  the  loss,  the  greater  the 
danger.  Women  bear  the  loss  of  blood  better  than  men.  Children  and  aged 
people,  as  well  as  stout  persons,  do  not  bear  the  loss  of  blood  at  all  well. 
Arterial  hemorrhage  produces  greater  depression  than  venous. 

If  death  does  not  occur,  there  is  a  reactionarj'  stage.  The  occurrence  of 
fever  has  been  noted  (hemorrhagic  fever),  but  it  is  difficult  to  separate  this 
from  febrile  disturbances  due  to  septic  changes.  Convalescence  is  slow,  and 
a  condition  of  chronic  anemia  may  last  for  a  long  time. 

(For  treatment  of  hemorrhage,  .see  Operations  on  Blood-vessels,  page 
336.) 

LIGATION  OF  ARTERIES 

The  most  simple  and  trustworth>-  method  of  closing  an  incised  or  punctured 
wound  of  an  artery  is  by  ligation.  After  ligation  of  an  artery  in  con- 
tinuity certain  changes  take  place  in  the  neighboring  circulatory  appa- 
ratus. At  the  moment  when  the  flow  of  blood  in  the  tube  is  obstructed  the 
current  at  once  sets  in  the  direction  of  the  lateral  branches  which  are  given  off 
nearest  the  seat  of  ligation,  with  an  increased  pressure.  These  lateral  branches, 
in  their  turn,  communicate  with  arteries  given  off  from  the  arterial  trunk 
beyond  the  place  at  which  the  ligature  is  applied,  and  thus  the  blood  finally 
reaches  its  original  destination,  albeit  by  a  more  or  less  roundabout  course. 
The  completed  circulation  thus  established  is  kno^Rii  as  the  collateral  cir- 


90 


INJURIES    AND    DISEASES    OF    SEPARATE    TISSUES 


culation  (Fig.  19).  This  anastomotic  or  collateral  circulation  is  usually 
restored  at  once  in  every  ligated  artery,  and  makes  for  itself,  according  to 
the  number  of  the  collateral  branches  and  the  amount  of  the  blood-pressure, 
more  or  less  wide  channels  for  carrying  on  the  circulation.  The  combined  area 
of  the  collateral  branches  equals  that  of  the  trunk  which  has  been  ligated,  and 
the  blood-supply  normal  to  the  part  is  finally  furnished.  The  exception 
to  the  rule  is  found  in  cases  in  which  diseased  conditions  of  the  arteries  or 
infiltration  of  the  surrounding  tissues  prevents  a  prompt  enlargement  of  the 
anastomosing  branches,  and  thus  the  blood-supply  to  the  periphery  is 
retarded  or  entirely  prevented.     Under  these   circumstances  gangrene  is  the 

inevitable  result. 

The  Changes  Which  Occur  in  the  Vessel. — 
When  an  artery  with  healthy  walls  is  tightly  con- 
stricted by  a  ligature  secured  by  a  knot,  the  two 
inner  coats  or  tunics  proper,  the  intima  and 
media,  give  wa}^  and  are  separated  by  the  pres- 
sure of  the  thread.  The  adventitia  or  external 
coat,  however,  remains  intact,  but  is  constricted 
in  a  narrow  circle.  The  intima  and  media, 
mainly  from  their  elasticity,  retract  or  curl 
upon  themselves  as  their  division  takes  place, 
and,  the  longitudinal  elastic  tension  on  the 
arterial  tube  being  relieved  b}^  the  division  of 
the  elastic  middle  coat,  on  which  it  depends,  a 
separation  of  the  divided  ends  occurs  to  a  greater 
or  lesser  extent.  The  vessel  just  beyond  the  limit 
of  the  clot  is  constricted  somewhat,  this  con- 
striction varying  with  the  particular  artery 
involved. 

The  application  of  a  ligature  in  such  a  man- 
ner as  simpty  to  occlude,  but  not  rupture  any 
of  the  coats  of  an  artery,  two  or  more  ligatures 
being  placed  side  by  side  and  tied  by  a  so-called 
''stay-knot"  (see  Fig.  128)  for  this  purpose,  has 
been  proposed  as  a  substitute  for  the  ordinary 
method  of  ligation  in  which  rupture  of  the  two  inner 
coatstakesplace(B  a  1 1  a  n  c  e  and  Edmunds). 
Changes  Which  the  Blood  Undergoes. — It  was  formerly  supposed  that 
the  mere  arrest  of  the  blood  at  the  point  of  ligation  was  sufficient  to  permit 
its  coagulation,  this  arrest  giving  opportunity  for  the  fibrinoplastin,  or 
paraglobulin  (Schmidt),  and  the  fibrinogen  to  act  on  each  other.  Later 
researches,  however,  have  shown  that  a  third  body  of  the  nature  of  a  ferment 
is  needed.  This  has  been  shown  to  have  its  origin  in  the  so-called  "blood- 
plaques,"  the  death  and  disintegration  of  which  give  rise  to  the  ferment.  The 
coats  of  the  artery  being  ruptured,  fibrin  is  first  deposited  on  the  damaged 
recurved  tunics;  the  disintegration  of  the  cell  containing  the  fibrin  ferment 
is  thereby  initiated.  When  the  coats  are  uninjured,  as  may  happen,  either 
intentionally  or  otherwise,  it  has  been  asserted  that  clotting  does  not  take 
place,  particularly  on  the   side   above    the   ligature,  nor  where   a   collateral 


Fig.  19. — Schematic  Representa- 
tion OF  AN  Artery  Ligated 
IN  Continuity. 

Showing  the  estabUshed  col- 
lateral circulation  and  the  forma- 
tion of  the  clot  (after  Hueter). 


INJURIES    AND    DISEASES    OF    BLOOD-VESSELS  91 

branch  of  sullicient  size  exists  (D  e  ii  t  and  I)  e  1  6  p  i  n  c  ,  Paul  B  r  u  n  s). 
It  has  been  maintained  that  the  two  opposing  surfaces  maybe  made  to  cohere  by 
nuiltiplication  of  tlie  endothelial  cells,  without  the  formation  of  a  clot  (R  i  e - 
del).  On  the  other  hand,  experiments  made  with  reference  to  this  point  show 
that  clotting  always  takes  place,  whether  the  tunics  are  ruptured  or  not, 
Furthermore,  the  presence  of  collateral  branches  of  not  inconsiderable  size 
in  the  immediate  neigh) )orhood  does  not  interfere  with  the  formation  of  a  clot, 
the  latter  not  infrecjueutly  passing  into  these  (B  a  1 1  a  n  c  e  and  Edmunds). 
The  view  that  coagulation  always  takes  place  when  the  normal  conditions  of 
the  vessel  are  interfered  with  sufficiently  to  prevent  the  blood-current  from 
continuing  its  course  through  the  same,  even  when  the  tunics  are  not  ruptured, 
is  probably  the  correct  one  (Michael  Foster).  Under  these  circum- 
stances a  profound  alteration  in  nutrition  is  established,  the  vasa  vasorum 
become  blocked,  and  a  plastic  effusion  ensues  as  a  result  of  the  presence  of 
the  ligature,  which  acts  as  a  foreign  body.  The  effusion  buries  the  loop  of  the 
ligature,  this  taking  place  sometimes  as  early  as  thirty  hours  after  the  operation. 
Simultaneously  the  opposed  endothelial  surfaces  proliferate  and  adhesions  form 
between  them  (B  a  1 1  a  n  c  e  and  E  d  m  u  n  d  s).  The  formation  of  the  coagu- 
lum  does  not  take  place  so  rapidly  with  unruptured  coats  as  with  ruptured 
ones.  This  is  due  to  the  fact  that  the  fibrin  is  not  deposited  until  the  occur- 
rence of  the  blocking  of  the  vasa  vasorum,  the  exudation  of  plasma,  and  the 
migration  of  the  leukocytes.  The  coagulation,  under  conditions  favoring  its 
occurrence,  may  be  initiated  in  an  hour.  It  is  not  likely  to  be  delayed 
beyond  six  hours. 

In  small  vessels  the  coagulation  takes  place  up  to  the  nearest  collateral 
branch.  In  the  large  vessels  this  varies.  The  proximal  clot  is  general^ 
the  larger.  Immediately  above  the  ligature  an  apparent  ampulla  is  formed 
(B  r  y  a  n  t) .  This  enlargement  in  reality  depends  on  a  contraction  of  the 
vessel  above  the  clot  (W  a  r  r  e  n) .  The  clot  does  not  distend  the  vessel  ; 
it  fits  the  tube  but  loosely,  and  a  space  is  frequently  found  between  the 
clot  and  the  surface  of  the  tunica  intima,  though  the  clot  is  attached  to  the 
latter  here  and  there. 

The  Function  of  the  Clot. — The  clot  takes  no  part  in  the  process  by 
means  of  which  the  obliteration  of  the  vessel  is  produced.  Its  function  seems 
to  be  threefold:  (1)  it  acts  as  a  cushion  against  which  the  impulse  of  the  blood 
is  received,  and  in  this  manner  prevents  any  disturbance  of  the  plastic  pro- 
cesses which  are  in  progress  at  the  seat  of  the  ligature;  (2)  it  forms  in  this 
situation,  as  in  other  localities  where  processes  of  repair  are  going  on,  a  trellis- 
work  support  to  cell  invasion,  as  the  latter  proliferates  from  side  to  side  of  the 
interior  of  the  arterial  tube;   (3)  it  serves  as  nutriment  for  these  cells. 

The  Fate  of  the  Ligature. — A  ligature  applied  to  a  blood-vessel  is 
always  treated  by  the  tissues  as  a  foreign  body  and  an  attempt  made  at  once  on 
the  part  of  the  cells  to  absorb  it.  The  material  of  which  the  ligature  is  com- 
posed will  determine  the  success  of  this  attempt.  In  the  case  of  gold  or  plati- 
num mre,  this  remains  permanently  in  an  unchanged  condition.  Ligatures 
of  silver,  lead,  iron,  and  other  metals  become  absorbed  sooner  or  later.  AU 
animal  and  vegetable  ligatures  disappear  in  time,  this  var^-ing  vdth  the  char- 
acter of  the  ligature  material  and  the  method  of  its  preparation. 


92  INJURIES   AXD   DISEASES    OF   SEPARATE   TISSUES 

If  no  bacterial  infection  follows  the  operation  the  wound  will  unite  by 
first  intention,  a  mass  of  plasma-cells  rapidl}^  surrounding  the  ligature.  This 
collection  of  cells  will  be  greater  on  the  tissue  than  on  the  vessel  side  of 
the  ligature.  The  plasma-cells,  in  attacking  the  ligature,  provided  it  is  of 
a  material  which  will  permit  its  absorption,  such  as  catgut,  kangaroo  tendon, 
reindeer  tendon,  silk  or  Chinese  twist,  etc.,  penetrate  into  its  interior  as  well, 
and  its  more  or  less  rapid  absorption  follows.  If  there  is  an}-  delay  in  the 
absorption,  encapsulation  occurs  from  the  formation  of  connective  tissue;  the 
absorption  is  not  on  this  account  arrested,  but  goes  on,  although  slowly,  to 
completion.  As  absorption  takes  place,  the  ligature  material  is  replaced  by 
new  connective  tissue.  In  the  case  of  animal  ligatures  the  softening  and 
absorption  of  the  ligature  occur  earlier  if  suppuration  takes  place.  T'nder 
these  circumstances  catgut,  unless  chromicized  or  otherwise  hardened,  may 
completely  disappear  in  fourteen  days.  Good  chromic  gut,  however,  in  a 
septic  wound,  may  be  relied  upon  to  hold  sufficiently  long  for  all  purposes  of 
ligation;  ordinaiy  gut,  prepared  by  boiling  in  alcohol,  will,  in  general  opera- 
tive work  of  an  aseptic  nature,  be  foimd  to  be  entireh"  trustworthy.  But 
in  hgation  in  continuity  of  large  arteries  near  the  heart,  in  which  case 
special  precaution  is  necessary,  well-chromicized  catgut  ^^■ill  be  the  safest  to 
employ. 

The  reparative  process  by  means  of  which  the  final  obliteration  takes  place 
does  not  differ  materially,  after  the  formation  of  the  clot,  from  that  which 
occurs  elsewhere.  The  proliferation  of  the  cellular  elements  of  the  intima 
leads  to  connective-tissue  formation,  the  clot  is  inA^aded  by  the  cell  growth,  and 
a  regenerative  or  hyperplastic  inflammator}-  condition  occurs,  somewhat 
resembling  that  which  marks  the  formation  of  callus  after  fracture  of  a  bone 
(see  page  130). 

If  the  Hgature  does  not  occlude  the  arterv'  at  the  time  of  the  operation,  or 
if  it  is  of  such  material  or  the  conduct  of  the  wound  is  such  as  to  lead  to  the 
too  rapid  softening  of  the  ligature,  or  if  the  knot  gives  way  too  early,  the 
circulation  through  the  vessel  may  become  reestablished.  This  may  occur 
in  cases  in  which  the  internal  coat  of  the  arter\-  is  not  ruptured,  and  also  where 
the  external  coat  or  adventitia  is  completely  divided.  Again,  it  may  happen 
that  a  diaphragm  forms  between  the  ligated  ends  of  the  vessel,  through  which 
a  central  opening  passes. 

Reestablishment  of  the  circulation  after  a  clot  has  formed  may  take  place  in 
one  of  three  ways:  (1)  The  central  mass  is  divided  by  cell  in\-asion  in  such  a 
manner  as  to  form  spaces,  which  are  bounded  tOAvard  the  center  of  the  clot  by 
endothelial  cells,  and  externally  by  the  intima  of  the  vessel,  these  constituting 
true  blood-channels.  If  the  force  of  the  blood-current  is  sufficient,  these  may 
be  so  enlarged  that  they  will  be  converted  into  one,  the  young  and  slender  con- 
nections between  the  lining  of  the  vessel  and  the  central  clot  giving  wa}-.  In 
this  way  a  peripheral  reopening  of  the  vessel  lumen  may  take  place.  (2)  The 
vessel  may  become  peiwious  by  an  opening  forming  through  the  center  of  the 
clot.  If  the  development  of  connective  tissue  does  not  proceed  in  such  a 
manner  as  to  protect  the  cells  or  granular  material  of  which  the  portions  of  the 
clot  between  the  spaces  are  made  up,  these  may  be  washed  away  and  the 
former  transformed  into  lacunae  filled  with  moving  blood,  so  that  the  circula- 
tion is  accomplished  through  a  kind  of  cribriform  or  sieve-like  membrane, 


INJURIES    AND    DISEASES    OF    BLOOD-VESSELS  93 

wliich  takes  the  place  of  the  oris:inal  clot.  (3)  The  connective-tissue  develop- 
ment taking  place  more  rapidly  in  the  periphery  than  in  the  center  of  the 
clot,  the  latter  of   which   is   the  natural   course,  true   canalization   of  the 

clot  may  occur. 

DISEASES  OF  ARTERIES 

.Arteritis. — The  influence  of  surrounding  conditions  of  infection  of 
arteries,  or  so-called  perivascular  suppuration,  is  such  as  to  induce  suppura- 
tive inflammation  of  the  vessels  of  the  arteries.  The  vessels  of  the  connective 
tissue  covering  the  artery,  or  the  adventitia.  are  chiefly  affected.  The  inter- 
ference with  the  nutrition  of  the  artery  is  such  as  to  lead  to  coagulation  in 
the  latter,  particularly  in  the  smaller  arteries  (intra-arterial  thrombosis). 
Injury  of  the  wall  of  the  vessel,  the  re.sulting  coagulation  undergoing  suppura- 
tion, is  followed  by  thrombo-arteritis.  Larger  arteries  do  not  suffer  so 
readily  from  attacks  of  suppurative  inflammation :  they  have  been  observed  to 
resist  for  a  Ions:  time  the  influence  of  .suiTOunding  septic  conditions. 

Chronic  arteritis  is  more  frecpently  observed  than  the  acute  form.  The 
chronic  form  of  the  chsease  (1)  may  result  from  previously  existing  degen- 
erative processes,  or  may  accompany  the  latter;  (2)  may  precede  these 
degenerations  and  be  the  initial  factor  ui  their  production.  The  degenera- 
tiA'e  processes  wliieh  mvade  the  arteiy.  and  wliich  may  be  accompanied  or  fol- 
lowed by  a  chronic  arteritis,  are  fatty  degeneration  and  calcification  of  the 
intima.  and  amyloid  degeneration  of  the  mtima  and  media. 

The  chronic  mflammation  of  the  arteri*  known  as  endarteritis  deformans 
is  the  most  common  form  of  the  disease.  It  usuaUy  occurs  in  persons  beyond 
middle  Ufe :  it  is  veiy  rarely  observed  m  those  under  fifty.  It  begins  iu  the  shape 
of  small  yeUowish  spots  on  the  iutima,  and  is  suggestive  of  a  fatty  granular 
degeneration  of  the  subendothehal  layer.  These  spots  coalesce  and  form 
placjues.  which  finally  undergo  calcification.  Tins  is  the  course  usuaUy  followed, 
but  somewhat  rarely  the  fatty  softening  proceeds  to  the  formation  of  excavations 
filled  with  detritus,  this,  on  accoimt  of  a  fancied  resemblance  to  retention 
cv'sts  of  sebaceous  glands  (the  so-called  atheromas),  constituting  the  concUtion 
known  as  atheromatous  degeneration.  In  chronic  endarteritis  the  rigicUty 
of  the  waUs  of  the  vessel  is  not  due  to  an  atheromatous  condition,  but 
rather  to  u^egular  condensation  and  thickening.  The  elastic  subendothe- 
hal layer  is  connected  with  a  more  or  less  soUd  membrane  in  cases  of  calcifica- 
tion; the  loss  of  elasticity  due  to  this  leads  to  dilatation  of  the  arterial  tube. 
with  lengthening,  and  the  production,  sometimes,  of  a  serpentine  coiu-se  of 
the  arter}-.  Tliis  can  be  often  observed  m  the  supei-ficial  arteries  of  old  people, 
particidarly  m  the  temporal  and  rachal  arteries,  occurring  comcidentally  with 
other  senile  changes  and  perceptible  both  by  touch  and  b}'  sight.  The  disease 
is_not  confined  to  these  vessels,  however,  but  occurs  thi'oughout  the  entire 
arterial  system,  mcluding  the  coronaiy  arteries  and  the  siulface  of  the  mitral 
valve. 

There  are  two  forms  of  surgical  cUsease  which  foUow  clu'onic  endarteritis  or 
are  in  close  association  with  it.  These  are  senile  gangrene  and  aneurism. 
The  first-named  affection  ^iU  be  discussed  more  fidly  among  the  cUseases  of 
the  lower  extremities,  for  the  reason  that  it  makes  its  first  appearance,  as  a 
rule,  in  that  locality.  It  may  be  said,  however,  that  calcification  of  the  arteries 
is  m  most  instances  the  cause  of  senOe  gano-rene;   it  mav  be  so  considerable 


94 


INJURIES   AND    DISEASES   OF   SEPARATE   TISSUES 


as  completely  to  obliterate  the  lumen  of  the  vessel,  and  thus  the  supply  of 
blood  is  shut  off  from  its  area  of  distribution.  Obstruction  of  smaller  branches 
of  the  main  trunk  may  result  from  the  loosening  of  the  calcified  patches,  which 
are  carried  as  emboli  by  the  blood-current  until  they  reach  the  smaller  arteries, 
where  they  lodge  and  obstruct  the  circulation.  The  occurrence  of  embolism 
is  characterized  by  severe  pains  in  the  regions  of  the  nerves  supplied  by  the 
vessel  involved.  If  the  collateral  circulation  is  insufficient,  stasis  occurs  in 
the  capillaries,  the  local  temperature  is  lowered,  and  gangrene  follows  (embolic 
gangrene). 


Fig.  20. — Schematic  Representation  of  the  Different  Forms  of  Aneurism  (after  Manteuffel). 
A,  Sacciform  aneurism;  B,  cylindriform  aneurism  ;  C,  fusiform  aneurism;  D,  dissecting  aneurism; 
E,  the  mechanism  of  the  production  of  the  diffuse  form  of  sacciform  aneurism  through  rupture  of  the 
elastic  elements  of  the  arterial  coats;  ¥,  arteriovenous  aneurism,  showing  a  direct  communication  between 
the  artery  and  the  vein,  with  dilatation  of  the  vein  alone;  G,  arteriovenous  aneurism,  with  dilatation 
of  both  artery  and  vein;  H,  arteriovenous  aneurism  with  the  formation  of  a  sac  between  the  artery  and 
the  vein. 

Aneurism. — Aneurism  is  a  dilatation  of  the  lumen  of  an  artery  filled  with 
circulating  blood.  This  definition  includes  dilatation  limited  to  a  portion  of 
the  artery,  as  well  as  the  condition  in  which  an  enlargement  of  the  entire 
arterial  system  of  a  part  occurs  (cirsoid  aneurism). 

Aneurisms  are  classified  on  the  basis  of  an  invariable  involvement,  or 
otherwise,  of  all  the  coats  of  the  vessel  in  the  disease.  The  first-named  con- 
dition is  known  as  true  aneurism,  while  the  second  is  called  false  aneurism. 

True  aneurisms  are  divided,  according  to  their  shape,  into  (1)  sacciform; 


INJURIES   AND    DISEASES   OF    BLOOD-VESSELS  95 

(2)  cylindriforai;  (3)  fusiform  (Fig.  20).  These  forms  are  nontraumatic 
in  origin,  ami  are  marked  l)y  a  gradual  dilatation  of  the  vessel;  the  dilatation 
takes'ono  or  more  of  these  shapes  according  as  the  entire  circumference  of  the 
vessel,  or  onlv  a  i)ortion  thereof,  is  involved. 

False  aneurisms,  or  those  in  which  ah  the  coats  of  the  vessels  do  not  take 
part  in  the  enlargement,  are  usually  the  result  of  an  injury  involving  partial 
division  or  destruction  of  the  arterial  wall.  The  mycotic  form  may  also  occur 
as  a  false  aneurism. 

Occurrence  of  Aneurisms.— True  aneurism  occurs  most  freciuently  in 
the  decade  between  thirt}-  and  forty  years  of  age,  when  structuraU-hanges  in 
the  arterial  coats,  due  to  syphilis,  rheumatism,  gout,  and  excesses  in  diet,  are 
most  common.  It  is  very  rare  before  puberty,  and  the  frequency  of  its  occur- 
rence gradually  decreases  after  the  age  of  forty,  w^hen  the  heart's  action  grad- 
ualh-  becomes  weakened.  Less  than  19  per  cent  occurs  in  women  (L  ii  t  - 
tich).  It  is  more  common  in  cold  than  in  hot  countries.  It  occurs  most 
commonly  in  the  following  vessels,  mentioned  in  the  order  of  frequency  of  occur- 
rence of  the  aneurism:  The  ascending  and  transverse  portions  of  the  thoracic 
aorta;  the  popliteal,  carotid,  subclavian,  innominate,  and  axillary'  arteries. 
Cirsoid  aneurism  occms  especially  on  the  scalp,  and  is  usually  congenital. 
Rarely,  it  occurs  from  some  mechanic  injury. 

Etiology.— Etiologically  all  aneurisms  are  either  dilatation  aneurisms 
or  rupture  aneurisms.  All  diseased  conditions  or  injuries  of  the  arteries 
by  which  the  strength  and  elasticity  of  their  walls  are  dimuiished,  may  give 
rise  to  either  one  or  the  other  of  these  forms.  These  include  the  foUo\\-ing: 
(1)  chronic  endarteritis;  (2)  periarteritis  with  secondary-  atrophy  of  the 
media;  (3)  contusions,  wounds,  and  subcutaneous  ruptures  of  arteries  and 
their  sequels  (cicatricial  weakening  of  the  vessel  wall) ;  (4)  degeneration  of  the 
vessel  wall  through  infectious  diseases  (typhus,  etc.). 

Sometimes  a  combination  of  circumstances  operates  to  produce  the  aneu- 
rism, such,  for  instance,  as  the  presence  of  primaiy  ruptures  of  the  media  due 
to  a  diseased  condition  or  traumatism,  and  a  marked  elevation  of  blood- 
pressure  from  some  strong  physical  exertion  or  violent  emotion,  whereby  the 
resistance  of  the  arterial  wall  is  overcome.  Syphilis  is  a  frequent  cause  of 
aneurism  of  the  aorta. 

Aneurism  arising  from  endarteritis  may  partake  of  either  the  sacciform, 
the  cylindriform,  or"  the  fusiform  shape.  In  the  first  two  the  entire  circum- 
ference of  the  vessel  may  be  involved,  while  in  the  latter  only  a  portion  of  this 
forms  the  aneurism.  Where  the  diseased  portion  of  the  vessel,  although 
occupying  the  entire  circumference,  is  sharply  limited  in  a  longitudinal  direc- 
tion the  aneurism  will  be  cylindriform  (Fig.  20.  B) :  where  the  limits  of  the 
diseased  portion  are  not  so  sharply  defined,  but  merge  gradually  into  the 
adjoining  and  less  diseased  portion,  the  aneurism  will  be  fusiform  (Fig.  20,  C). 
Where  dilatation  takes  place  at  a  single  point  and  but  a  portion  of  the  circumfer- 
ence of  the  vessel  is  involved  (E  p  p  i  n  g  e  r).  the  aneurism  will  be  sacciform 
(Fig.  20.  A).  In  the  more  or  less  diffused  forms  the  elastic  elements  of  the 
arterial  coats  give  way  at  numerous  points  in  the  same  locality  (Reckling- 
hausen) (Fig.  20,  E).  Endarteritis  being  a  more  or  less  widely  diffused 
disease  of  the  vessels,  dilatation  may  occur  at  several  points  in  the  same 
vessel,  or  may  be  present  in  several  vessels  at  the  same  time. 


96  INJURIES    AND    DISEASES    OF    SEPARATE    TISSUES 

Locality  has  some  influence  in  the  development  of  aneurisms.  They  have 
a  special  predilection  for  those  portions  of  arteries  where  divisions  of  main 
trunks  occur,  as,  for  instance,  the  point  of  division  of  the  innominate,  of  the 
common  carotid,  of  the  femoral  where  the  profunda  is  given  off,  and  of  the 
popliteal  where  it  divides  into  the  anterior  and  posterior  tibial.  This  seems  to 
arise  from  the  fact  that  a  slight  fusiform  dilatation  occurs  at  these  points 
normally,  and  under  pathologic  conditions  further  enlargement  occurs  the 
more  easilv.  Aneurism  is  also  more  likely  to  occur  where  the  artery  is  embedded 
in  soft  tissues  with  absence  of  firm  external  support.  It  likewise  tends  to 
arise  where  the  vessels  are  exposed  to  injury  at  the  points  of  flexion  of  the 
extremities. 

False  Aneurism. — This  includes  all  forms  in  which  one  or  another,  or  all 
three  of  the  coats  of  the  vessel  are  missing  from  the  wall  of  the  aneurism. 
Traumatic  aneurism  is  the  most  common  variety  of  false  aneurism. 

Traumatic  Aneurism. — This  may  arise  from  simple  contusion  of  the 
vessel  through  consequent  perforation  by  necrobiosis,  though  M  a  c  k  o  w  '  s 
experiments  tend  to  show  that  contusions  undergo  repair  at  first.  Subsec^uent 
yielding  of  the  cicatrix  may  give  rise  to  aneurism.  It  is  usually  due,  however, 
to  partial  division  of  the  vessel.  Complete  division  of  an  artery  does  not 
develop  into  aneurism  except  in  the  rare  instances  in  which  it  arises  from  the 
presence  of  a  diseased  vessel  lying  in  a  dead  space  and  being  without  adec|uate 
support,  in  an  amputation  stump,  or  from  improper  ligation  or  the  premature 
giving  wa}'  of  a  properly  applied  ligature,  and  the  subsequent  canalization  of  a 
hematoma.  The  aneurisms  arising  from  a  punctured  injury  result  from  a 
gradual  yielding  of  the  thrombus  which  forms,  and  of  the  surrounding  con- 
nective tissue,  from  intra-arterial  pressure.  Under  these  circumstances  the 
sac  which  develops  is  made  up,  first,  of  the  outer  layer  of  the  thrombus, 
and  finally  of  the  newly  formed  connective  tissue,  supported  by  the  surround- 
ing soft  parts.  In  subcutaneous  rupture  of  a  large  artery  there  is  more  or 
less  separation  of  the  coats  of  the  vessel  in  a  transverse  direction,  and  extensive 
extravasation  of  blood  in  the  perivascular  connective  tissue  of  the  sheath  of 
the  vessel,  which  finally  forms  the  wall  of  the  sac  of  the  aneurism.  In  dissect- 
ing aneurism  rupture  of  the  intima  and  media  takes  place,  with  preser^^ation 
of  the  adventitia.  The  blood  dissects  its  ^vay  between  the  media  and  the 
adventitia,  separating  these  from  each  other.  In  hernial  aneurism  the 
defect  is  in  the  adventitia,  and  the  inner  and  middle  coats  are  forced  through 
the  opening. 

Arteriovenous  Aneurism  (Fig.  20,  F,  G,  and  H). — This  results  from  the 
simultaneous  lateral  injury  of  an  artery  and  a  neighboring  vein,  in  which 
either  a  sac  is  formed  in  the  connective-tissue  sheath  common  to  both,  or 
direct  agglutination  of  the  artery  and  vein  takes  place  at  the  point  of  injury. 
The  wound  of  the  artery  and  that  of  the  vein,  if  directly  in  apposition,  result 
in  the  formation  of  an  arteriovenous  aneurism  or  aneurism  by  anastomosis 
(Hunter)  (aneurismal  varix,  varicose  aneurism).  This  originates  in  stab 
or  shot  wounds,  and  abrasions  by  exostosis.  In  former  times  phlebotomy  was 
a  frequent  cause.  It  has  been  obser^-ed  in  amputated  stumps.  In  arterio- 
venous aneurism  the  arterial  blood  invades  the  vein  and  produces  pulsation 
in  the  latter,  with  marked  disturbance  of  the  circulation,  and  pulsating  dila- 
tations of  the  branches  of  both  arten'  and  vein. 


INJURIES    AND    DISEASES    OF    BLOOD-VESSELS  97 

Pathologic  Anatomy, — True  aneurism  contains  within  its  walls  all  the 
constituents  of  the  normal  arterial  wall,  only  altered  and  attenuated.  Strata 
of  shell-like  thrombi  line  the  inner  wall  concentrically  in  large  sacciform 
aneui-isms.  Dissecting  aneurism  shows  a  defect  in  the  intima;  in  hernial 
aneurism  the  defect  is  in  the  ach entitia  and  muscularis.  lalse  aneurism 
arises  in  the  beginning  from  the  fluid  center  of  a  hematoma;  later  the  sac 
develops  from  the  c()nno(•ti^■e  tissue. 

The  Symptoms  of  Aneurism. — The  presence  of  a  pulsating  tumor  is  the 
most  important  symptom  of  aneurism.  The  tumor  will  vary  in  size  from  a 
millet-seed  to  an  adult  head.  The  pulsation  can  be  distinguished  by  the  eye; 
each  systolic  act  of  the  heart  causes  the  tumor  to  pulsate,  relaxing  at  the 
diastole.  A  thrill  or  soft  friction  sensation  is  conveyed  to  the  examining 
finger  by  the  passage  of  the  Ijlood  over  the  rough  walls  of  the  sac.  This  latter 
symptom  is  heard,  by  the  aid  of  the  stethoscope,  as  a  rough  sound.  Symp- 
toms arising  from  pressure  on  surrounding  parts  are  the  following:  (1) 
pain  from  involvement  of  nerve-trunks  and  filaments;  (2)  obstruction  to  the 
return  circulation,  resulting,  in  the  case  of  the  extremities,  in  permanent  edema 
and  new  connective-tissue  growth,  simulating  elephantiasis;  (3)  erosion  and 
destruction  of  neighboring  bony  and  cartilaginous  parts. 

Diagnosis. — When  a  pulsating  tumor  is  present  the  following  points  must 
be  borne  in  mind:  (1)  The  pulsation  is  expansile,  i.  e.,  it  is  felt  to  take  place 
in  all  directions.  In  this  manner  an  abscess  which  may  rise  and  fall  from 
proximity  to  a  large  vessel  may  be  differentiated  from  an  aneurism.  (2)  Com- 
pression of  the  artery  between  the  tumor  and  the  heart  causes  lessening 
or  disappearance  of  the  tumor,  and  arrests  its  pulsation  and  the  thrill  or  fric- 
tion sound.  (3)  In  aneurism  the  pulsating  wave  in  the  peripheral  por- 
tion of  the  artery  is  retarded  as  compared  with  that  of  the  corresponding 
healthy  vessel.  In  the  sphygmographic  tracing  the  curve  is  flattened  and 
the  point  disappears.  (4)  The  presence  of  a  considerable  amount  of  fibrinous 
coagulum  within  the  sac  may  mask  the  pulsation.  (5)  Pulsation  may  occur 
in  localities  where  contact  with  large  vessels  does  not  exist,  as,  for  instance, 
the  pulsation  of  the  brain  may  become  visible  in  case  of  a  bony  defect  in  the 
skull ;  the  exposed  medullary  tissue  of  the  long  bones  in  some  instances  is  seen 
to  pulsate;  thyroid  or  other  highly  vascular  tumors,  and  certain  varieties  of 
osteosarcoma,  likewise  present  this  symptom. 

The  Terminations  of  Aneurism. — The  spontaneous  cure  of  traumatic 
aneurism  occurs  not  infrequently.  Stratiform  deposits  of  solid  masses  of 
fibrin  on  the  internal  wall  of  the  sac  occur,  the  excavated  portion,  as  well 
as  the  lumen  of  the  vessel,  becomes  filled,  and  fibrinous  contraction  of  the  mass 
finally  produces  complete  obliteration.  Cure  by  nature's  efforts,  however, 
m  aneurism  depending  on  endarteritis  is  not  to  be  expected.  In  the  most 
favorable  cases  the  dilatation  may  remain  stationary.  Between  the  progressive 
character  of  the  endarteritis  on  the  one  hand,  and  the  continued  pressure  of 
the  blood-current  on  the  other,  steady  increase  of  the  dilatation  is  the  rule. 
Structures  other  than  the  arterial  walls  may  become  involved  in  the  disease. 
Large  aneurismal  dilatations  of  the  aorta  give  rise  to  erosions  of  bony  struc- 
tures; even  the  vertebral  column  is  invaded,  its  medullary  cavity  opened,  and 
the  spinal  cord  exposed.  Anteriorly  the  bony  chest  wall  disappears  over  a 
considerable  area  and  the  pulsating  mass  is  Adsible  externally.     Nerve-trunks, 


98  INJURIES   AND   DISEASES   OF   SEPARATE   TISSUES 

subjected  to  pressure,  are  disturbed  in  their  function;  violent  pain  or  paralysis 
results.  The  aneurism  may  open  externally,  the  overstretched  skin  ulcerat- 
ing rapidly  ;  fatal  hemorrhage  usually  follows.  Finally,  a  patient  with 
aneurism  is  subjected  to  the  dangers  of  embohsm. 

Treatment  of  Aneurism. — The  indications  for  treatment  include  the  fol- 
lowing: (1)  The  treatment  of  the  arteriosclerosis,  on  which  true  aneurism 
depends,  by  the  use  of  iodid  of  potassium,  whereby  it  is  hoped  to  arrest  the 
progress  of  the  disease.  (2)  The  lowering  of  the  blood-pressure,  both  the 
volume  and  the  force  of  the  blood-current  that  enter^^  the  sac  being  thereby 
lessened,  and  rest  in  the  recumbent  position  and  fasting  (Valsalva). 
The  subjective  symptoms  of  pressure  and  obstruction  are  relieved  by  these 
means.  (3)  Attempts  to  cause  coagulation  of  the  blood  entering  the  sac. 
(For  the  operative  treatment  of  aneurism  see  Operations  on  the  Blood-vessels.) 

INJURIES  AND  DISEASES  OF  VEINS 
Incised  and  punctured  wounds  behave  in  a  manner  similar  to  that  of 
arteries  under  the  same  circumstances.  The  walls  of  veins  contain  less 
elastic  and  contractile  tissue,  and  consequently  there  is  not  the  same  amount 
of  retraction  of  the  vessel  and  contraction  of  its  lumen  as  in  the  case  of 
arteries.  There  is  not,  therefore,  the  same  tendency  to  spontaneous  arrest 
of  hemorrhage  in  the  case  of  an  injured  vein  as  in  the  case  of  an  artery.- 
This  is  somewhat  compensated  for  by  the  fact  that  there  is  not  the  same 
amount  of  intravascular  pressure  in  the  veins  as  in  the  arteries,  and  blood 
is  not  so  rapidly  lost  from  this  source.  In  operation  wounds,  the  arteries 
supplying  the  parts  being  closed  by  ligation,  the  hemorrhage  from  the  veins 
becomes  less  troublesome,  from  the  fact  that  the  supply  of  blood  is  cut  off. 
It  is  fortunate  that  this  is  true,  for  the  reason  that  the  efferent  branches  of 
the  large  veins  have  very  extensive  and  firm  connections  to  the  surrounding 
structures,  in  order  to  meet  fulty  the  demands  made  by  constantly  changing 
intra-arterial  blood-pressure.  These  connections,  each  one  of  which  is  a- small 
vein,  if  supplied  with  blood  with  the  same  force  of  current  as  that  which 
exists  in  the  arteries  w^oukl  increase  very  greatly  the  difficulty  of  arresting 
venous  hemorrhage.  Although  venous  hemorrhage  is  not  so  serious  an 
accident  as  arterial,  yet,  under  certain  circumstances,  a  large  amount  of  blood 
may  be  lost  in  a  short  time.  Position,  for  instance,  has  a  very  decided 
tendency  to  increase  hemorrhage  from  a  vein.  Without  depending  on  the 
arterial  blood-pressure,  hemorrhage  from  a  subcutaneous  vein  with  the  body 
in  the  upright  position,  particularh^  if  this  vein  is  in  a  varicose  condi- 
tion, will  give  rise  to  serious  bleeding.  The  blood  here  escapes  from  the 
central  end  of  the  injured  vein  by  the  mere  weight  of  the  column  of  blood,  in 
spite  of  the  valvular  apparatus  of  the  veins  which  is  intended  to  prevent  reflux 
of  blood. 

Aspiration  of  Air  into  Veins. — A  special  danger  in  connection  with 
wounds  in  veins  at  the  root  of  the  neck  and  in  the  neighborhood  of  the 
superior  opening  of  the  chest  cavity  relates  to  the  intravenous  aspir- 
ation of  air.  Each  expiratory  effort  retards  the  return  of  the  blood 
from  the  head  and  upper  extremity  to  the  large  venous  trunk  within  the 
thorax,  and  tends  to  force  it  back  toward  the  periphery.  An  injury  to 
either  of  the  jugulars,  the  subclavian,  axillary,  or  subscapular  veins,  or  the  cere- 


IN.Tl'RIES    AND    DLSKASIOS    OF    BLOOD-VESSELS  99 

bral  sinuses,  ivsults  in  a  crowding  out  of  tlie  large  mass  of  dark  blood  from 
the  wound.  As  an  inspiration  takes  place  the  thorax  is  expanded,  and  the 
vacuum  thus  produced  is  filled  by  the  blood  rushing  into  the  intrathoracic 
vessels.  Whatever  fluid  other  than  blood  is  brought  within  the  range  of 
influence  of  this  suction  will  likewise  pass  in.  The  escape  of  blood  from  the 
wound  in  the  vein  is  held  temporarily  in  check  by  the  inspiratory  effort;  at  the 
same  time.,  however,  more  or  less  air  passes  into  the  vein,  producing,  in  its 
passage,  a  peculiar  hissing  sound  which,  once  heard,  is  never  forgotten  by  the 
surgeon.  Small  ([uantities  of  air  thus  aspirated  may  do  no  harm,  but  a  large 
quantity  may  cause  immediate  death.  The  exact  mechanism  by  which  this 
effect  is  produced  is  still  a  matter  of  dispute.  The  air  passes  from  the  right 
ventricle  into  the  pulmonary  circulation  in  aeriform  emboli,  the  result  of  a 
"churning"  process  which  the  mixed  air  and  blood  undergo  in  that  cavity  by 
the  contraction  of  the  heart  muscles.  The  emboli  fill  the  branches  of  the  pul- 
monary artery,  and,  these  being  obstructed,  stasis  occurs,  the  left  heart  collapses 
from  want  of  blood  on  which  to  contract,  and  fatal  syncope  residts  from 
failure  of  blood  to  reach  the  cerebrum,  while  at  the  same  time  the  right  heart 
is  paralyzed  from  inability  to  contract  on  the  mingled  mass  of  blood  and 
air  within  its  cavities.  Although  experiments  on  animals  have  repeatedly 
shown  that  quite  large  quantities  of  air  can  be  injected  into  the  veins  without 
producing  a  fatal  result,  yet  the  fact  remains  that  many  patients  have  died 
from  this  accident,  particularh^  during  operations  about  the  neck. 

The  diagnosis  between  venous  and  arterial  hemorrhage  is,  as  a  rule, 
easily  made.  The  former  flows  in  a  rather  continuous  stream,  while  the  latter 
is  forcibly  ejected  in  interrupted  jets.  The  blue  color  of  the  venous  blood  and 
the  red  color  of  the  arterial  blood  constitute  a  striking  difference.  Exception- 
ally, however,  this  differentiation  is  embarrassed  by  the  fact  that  the  dark 
color  of  venous  blood  becomes  changed  to  a  lighter  hue  by  contact  with  the 
air;  the  presence  of  arterial  blood  flowing  from  divided  arterioles  in  the  skin 
in  cases  of  punctured  wound  of  a  vein  may  likewise  mask  the  real  source  of 
the  more  serious  bleeding. 

Artificial  arrest  of  hemorrhage  from  a  vein  is  more  rarely  demanded  than  in 
the  case  of  arteries  of  the  same  size.  The  reasons  for  this  have  been  already 
mentioned.  Circumstances  frequently  arise,  however,  which  demand  prompt 
action,  both  on  account  of  the  quantity  of  blood  lost  and  on  account  of  the  dan- 
ger of  aspiration  of  air.  Prior  to  the  introduction  of  antiseptic  and  aseptic 
operative  technic  surgeons  aimed  to  avoid,  as  far  as  possible,  the  placing  of 
ligatures  on  veins.  Infection  and  suppuration  of  the  resulting  intravenous 
thrombus  occurred  frequently,  and  here,  as  in  the  case  of  decomposition  of  an 
intra-arterial  thrombus,  secondary  hemorrhage  was  liable  to  follow.  The 
detachment  of  portions  of  this  septic  clot,  its  passage  into  the  circulation, 
and  its  transportation  in  the  shape  of  emboli,  occurred  from  veins  as 
well  as  from  arteries.  On  this  account  ligation  of  the  veins  was  resorted  to 
only  in  the  most  urgent  cases.  The  introduction  of  the  aseptic  ligature, 
however,  has  changed  all  this,  and  at  the  present  day  the  application  of  the 
ligature  is  practised  on  veins  and  arteries  alike.  The  frequently  recom- 
mended and  as  frequently  rejected  lateral  ligation  of  veins  has  at  last  been 
placed  on  a  firm  scientific  footing  by  the  introduction  of  antiseptic  pro- 
cedures. That  the  closure  of  veins  without  the  formation  of  a  clot  may  occur 
has  been  proved. 


100  INJURIES    AND    DISEASES    OF    SEPARATE    TISSUES 

Varix. — The  condition  known  as  varix  consists  of  a  dilatation  of  the  lumen 
of  a  vein,  and  corresponds  to  dilatation  of  an  artery,  or  aneurism.  A  funda- 
mental difference  exists,  however,  in  the  method  of  origin  of  the  two  conditions. 
While  the  latter  occurs  either  as  the  result  of  injuries  to  the  arterial  wall  or 
from  the  presence  of  endarteritis,  the  former  is  the  result  of  passive  dilatation  of 
the  unchanged  walls  of  the  vein,  which  suffer  by  the  accumulation  of  venous 
blood.  The  obstruction  may  be  due  to  various  causes,  as  follows:  (1) 
occupations  involving  continuous  walking  or  standing,  the  weight  of  the 
column  of  blood  producing  pressure  on  the  lower  extremities;  (2)  the 
pressure  of  the  pregnant  uterus  and  of  large  intra-abdominal  tumors  on 
the  ascending  vena  cava;  (3)  physiologic  conditions  relating  particularly  to 
the  distance  of  the  parts  from  the  heart,  to  which  may  be  added  abnormal 
conditions  of  these  parts,  as  in  fractures  of  the  lower  extremities  followed 
by  the  formation  of  large  masses  of  callus,  the  presence  of  bone  tumors, 
etc.  It  may  also  be  due  to  cardiac  weakness  and  conditions  involving  obstruc- 
tion to  the  entrance  of  venous  blood  into  the  heart.  Pathologic  changes 
in  the  connective  tissue  surrounding  the  veins,  the  latter  losing  their  support 
from  without,  also  favor  the  origin  of  varix. 

Occurrence  of  Varix. — Varices  occur  more  frequently  in  the  lower  extrem- 
ities than  elsewhere.  For  the  purpose  of  surgical  study  we  may  group  all 
cases  subject  to  this  hemadynamic  condition  within  the  area  of  the  lower  half 
of  the  body,  where  the  return  flow  of  blood  in  the  veins  is  rendered  difficult. 
This  will  include  the  veins  of  the  spermatic  cord,  the  pampiniform  plexus,  the 
veins  of  the  lower  part  of  the  rectum  (hemorrhoidal),  and  those  of  the  lower 
extremity. 

Varicose  veins,  as  varices  are  sometimes  called,  undergo  lengthening 
somewhat  similar  to  that  which  occurs  in  arteries,  in  cases  of  endarteritis,  and 
in  aneurism.  In  the  case  of  varix,  however,  this  occurs  to  a  much  greater 
extent,  the  veins  pursuing  a  tortuous  course  with  numerous  convolutions. 
Under  the  influence  of  constant  pressure  on  the  walls  of  the  veins,  in  which 
elastic  fibers  exist  to  a  much  less  extent  than  in  arteries,  these  become 
thinned,  together  with  the  overlying  skin,  in  the  case  of  subcutaneous  veins. 
These  conditions  are  specially  prevalent  in  the  vessels  of  the  thigh  and  leg. 
Below  the  ankle,  as  a  rule,  only  a  fine  network  of  blue  lines  is  seen.  The  veins 
of  the  gastrocnemius  muscle  are  occasionally  affected.  Those  which  accom- 
pany the  arterial  trunks  are  comparatively  exempt.  The  same  may  be  said 
of  the  saphenous  vein,  the  dilated  veins  occurring  in  the  course  of  this  trunk 
beingreally  varices  of  the  branches  which  join  the  saphenous  near  its  upper  limit. 

Diagnosis. — Pressure  applied  directly  on  the  dark  blue,  cordlike  eleva- 
tions and  convolutions  will  cause  a  disappearance  of  the  varices,  while  pres- 
sure, centrally  applied,  will  cause  them  to  increase  in  size. 

Prognosis. — This,  as  far  as  danger  to  fife  is  concerned,  is  favorable.  Com- 
plications may  arise,  however,  from  the  presence  of  varicose  veins  which  may 
become  sources  of  great  inconvenience,  and  sometimes  of  real  danger.  Inter- 
ference with  the  function  of  parts,  particularly  of  the  skin,  leads  to  the  pro- 
duction of  inflammatory  and  suppurative  processes.  Eczema  occurs  in  the 
legs,  particularly  of  elderly  persons.  Ulceration  of  the  skin  follows  compara- 
tively slight  abrasions;  contusions  give  rise  to  sloughy  conditions.  Repair  goes 
on  verv  slowlv  under  these  circumstances. 


INJURIICS    AND    DISK  ASKS    OF    BLOOD-VKSSELS  101 

Complications  of  Varix. — Thr()nil)o,sis  sometimes  occurs  as  a  result  of 
retarded  circulation  in  vai'ix,  this  in  time  leading  to  obliteration  of  the  latter  by 
a  transformation  of  the  clot  into  solid  connective  tissue.  This  change  is  proba- 
bly due,  to  some  extent,  to  chronic  inflammatory  conditions  in  the  neighboring 
tissues.  The  hart!  mass  thus  formed  is  solidly  attached  to  the  walls  of  the 
vein,  and  to  the  touch  simulates  a  small  fibroma.  This  occasionally  becomes 
the  seat  of  tleposits  of  lime  salts,  constituting  the  so-called  phlebolith,  numbers 
of  which  may  exist  for  years  without  serious  inconvenience  to  the  patient. 

Rupture  of  a  varicose  vein  may  occasionally  threaten  life  from  profuse 
hemorrhage.  Patients  with  varicose  veins  should  be  taught  provisional 
methods  of  arresting  hemorrhage.  Peptic  changes  in  thrombi,  followed  by 
transportation  of  infectious  emboli  to  distant  parts,  may  occur.  Septic 
metastases  in  the  lungs  and  other  parts  (pyemia)  constitute  another  danger- 
ous complication.  The  latter  termination  is  fortunately  rare,  however,  for  the 
reason  that  the  inflammation  is  usually  limited  to  the  perivascular  spaces. 

Treatment, — This  may  be  divided  in  a  general  way  into  palliative  and 
curative.  The  former  consists  in  supporting  the  parts  surrounding  the  varices 
by  properly  applied  bandages  or  their  substitutes.  Compression  is  secured 
by  means  of  rubber  bandages  (Martin),  bandages  of  "stockinet"  mate- 
rial, and  stockings  made  of  silk  with  elastic  threads  interwoven.  Operative 
measures  will  vary  according  to  the  location  of  the  varices.  These  consist  of 
ligation,  with  or  without  excision,  as  in  varicocele,  and  in  some  cases  of 
superficial  varices  of  the  lower  extremities.  In  the  latter  cases,  however,  recur- 
rences are  rather  common.  Injection  of  solutions  of  ergotin  into  the  peri- 
vascular connective  tissue  has  been  followed  by  good  results  (Vogt).  Car- 
bolic acid,  sufficient  to  make  a  2  per  cent  solution  with  the  ergotin  solution, 
should  be  added.  Strict  aseptic  precautions  should  be  obser^•ed,  and  the 
point  of  puncture  made  by  the  hypodermic  needle  protected  by  a  drop  of 
iodoform  collodion. 

Ligation  of  the  internal  or  long  saphenous  vein  at  the  saphenous  open- 
ing, in  properly  selected  cases,  constitutes  one  of  the  best  operative  procedures 
for  varicose  veins  of  the  lower  extremity  (Trendelenburg).  The 
ligature  should  be  applied  below  the  point  where  the  superficial  circumflex  iliac 
and  superficial  epigastric  veins  join  the  saphenous  (see  page  351). 

Phlebitis. — Unlike  the  corresponding  condition  occurring  in  arteries,  acute 
suppurative  inflammation  of  the  veins,  or  phlebitis,  either  alone  or  complicat- 
ing subcutaneous  and  subfascial  phlegmonous  inflammation,  or  as  a  result 
of  these,  is  not  uncommon.  Plilebitis  pure  and  uncomplicated  occurs  most 
frequently  in  the  leg  and  thigh.  When  it  occurs  in  the  course  of  the  subcuta- 
neous veins  in  the  latter  situation,  the  hard  cordlike  lines  are  quite  easily  dis- 
tinguished. This  cordlike  hardness  arises  less  frequently  from  coagulation 
of  the  column  of  blood  in  the  inflamed  veins  than  from  more  or  less  dense 
cellular  infiltration  of  the  adventitia  and  perivascular  connective  tissue. 
Coagulation,  however,  does  occur  in  phlebitis,  and  is  the  result  of  a  deposit 
of  fibrin  on  the  diseased  intima. 

Thrombophlebitis  is  that  condition  in  which  a  suppurative  inflammation 
situated  peripherally  to  the  subsequently  inflamed  vein  causes  a  thrombosis  in 
the  latter,  the  phlebitis  resulting.  Here  a  minute  thrombus  forms  in  a  capil- 
lary, and,  charged  with  cocci,  it  is  carried  into  the  wall   of  the  vein  and 


102 


INJURIES    AND    DISEASES    OF    SEPARATE    TISSUES 


becomes  attached  to  it,  where  it  forms  the  nucleus  for  further  deposits  of  fibrin. 
These  in  their  turn  become  the  seat  of  renewed  suppuration  antl  infect  the  wall 
of  the  vein.  This  thrombus  may  develop,  by  further  deposit,  to  an  extent 
sufficient  to  produce  complete  obliteration  of  the  vein ;  it  may  likewise  extend 
into  the  next  larger  vein  (I-lg.  21)  or  still  further.  During  its  existence  the 
patient  is  exposed  to  all  the  dangers  of  pyemic  invasion  of  remote  parts. 

While  the  thrombi  just  described  have  their  origin  in  septic  inflammatory 
conditions,  either  from  the  bacteria  producing  the  coagulation  or  from  their 
influence  on  the  leukocytes  in  setting  free  the  fibrin  ferments  (see  page 
90),  thrombi  likewise  occur,  exclusive  of  these  influences,  in  otherwise 
healthy  veins.  These  coagulations  occur  as  the  so-called  stagnation 
thrombi.  This  thrombosis  rnay  happen  from  any  obstruction,  as,  for  instance, 
a  ligature  applied  so  as  to  obliterate  the  lumen  of  the  vein.  The  vein  from  the 
point  of  ligature  to  the  next  collateral  branch  is  filled  with  blood  (the  valvular 
apparatus  being  insufficient  to  prevent  this),  which  remains  for  a  time  in  a 
liquid  state.  Finally  coagulation  takes  place,  beginning  at  the  wall  of  the  vein, 
and  the  resulting  thrombus  obliterates  the  lumen.  The  continued  presence  of 
the  carbon  dioxid,  in  all  probability,  is  the  disturbing 
agent  of  the  leukocytes;  the  disturbances  which  follow 
result  in  the  setting  free  of  the  fibrin  ferment  neces- 
sary to  the  production  of  coagulation.  The  produc- 
tion of  stagnation  thrombosis  is  not  confined  to  cases 
of  ligation  of  a  vein,  but  may  result  from  any  cause 
which  produces  obstruction,  such,  for  instance,  as 
tumors  of  rapid  growth,  or  the  presence  of  two  or 
more  clots  which  invade  the  vein  at  different  parts 
of  its  course. 

Thrombosis. — The  retardation  of  the  current 
of  blood  in  the  veins  ma}'  also  produce  thrombosis. 
This  dilatation  thrombosis  occurring  in  varicose 
veins  is  the  result  of  over-accumulation  of  carbon 
dioxid,  and  takes  place  more  particularly  in  situations  where  the  blood 
collects  within  the  pouches  formed  by  the  valves  of  the  -v'eins.  Here,  also, 
the  disturbance  or  destruction  of  the  leukocytes  sets  free  the  fibrin  ferment 
and  coagulation  results.  These  valvular  thrombi  most  frequently  undergo 
fibromatous  change  and  calcification  (see  PlileboHths,  page  101). 

Finally,  a  thrombosis  is  ol)served  ^dth  advancing  years  after  debilitat- 
ing diseases,  to  which  the  name  marasmus  thrombosis  was  given  by  V  i  r  - 
chow.  With  the  lessening  of  the  cardiac  impulse,  the  influence  on  the 
weakened  circulation  is  such  as  to  produce  coagulation  at  certain  points  in 
the  venous  system.  The  diseases  of  greatest  interest  to  the  surgeon,  which 
give  rise  to  this  condition,  are  particularly  those  which  arise  from  infectious 
processes,  as  the  traumatic  septic  fevers.  In  these,  as  well  as  in  some 
other  diseases  resulting  from  infection,  it  is  believed  that  the  influence  of 
the  infectious  agents  in  the  blood  is  such  as  to  set  free  the  fibrin-forming  fer- 
ment, which  induces  coagulation  under  circumstances  favoring  retardation  of 
the  blood-current.  The  thrombi  which  are  thus  produced  are  usually  of  the 
vahiilar  variety  at  the  start,  but  they  may  easily  advance  into  the  lumen  of  the 
vessel,  or  extend  to  the  next  collateral  branch  (extension  thrombi).     The 


Fig.    21. — Thrombosis   from 
Small  to  Large  Vein. 


INJURIES    AND    DISEASIOS    OF    BLOOD-VESSELS  103 

favorite  sites  for  these  thrombi  are  the  femoral,  the  profunda,  and  the  common 
iliac  vein.  The  large  veins  in  the  muscles  of  the  thigh,  as  well  as  tlie  network 
of  veins  in  the  lesser  pelvis,  are  likewise  occasionally  involved. 

In  the  autops>'  room  are  fr(>([U(nitl>'  found  venous  thrombi  which  have 
occurred  after  death.  These  postmortem  thrombi  are  easily  distinguished  from 
those  occurring  during  life  by  reason  of  the  fact  that  they  are  not  closely  con- 
nected to  the  vessel  wall.  (3n  the  contrary,  they  are  either  loosely  connected 
to  the  intima  or  not  connected  to  it  at  all;  in  addition,  they  are  of  softer  con- 
sistency and  darker  in  color  than  true  thrombi.  Where  the  latter  occur  shortly 
before  death  there  is  a  possibility  of  error,  but  their  lighter  color  will  probably 
serve  to  aid  in  tlie  discrimination.  The  longer  the  interval  between  the 
formation  of  the  thrombi  and  the  death  of  the  patient,  the  more  intimately 
adherent  to  the  vessel  wall  will  the  former  be  found  to  be. 

The  prognosis  of  thrombosis  relates  principally  to  the  dangers  which  arise 
from  the  tendency  of  portions  of  the  fibrinous  mass  to  loosen  and  to  be  trans- 
ported to  other  parts  ]:)y  the  circulation.  These  dangers  are  increased  by 
the  possibilities  of  septic  conditions  and  suppuration,  particularly  in  phlebitis 
from  injury  to  veins.  The  danger  of  transportation  of  portions  of  thrombus 
arises  particularly  from  the  tendency  on  the  part  of  extension  clots  to  have 
their  terminating  extremities,  where  exposed  to  the  current  of  blood  in  the 
collateral  branches,  detached  and  swept  into  the  general  circulation.  These 
are  carried  in  a  centripetal  direction  to  the  right  heart,  unless  they  are  arrested 
en  route,  where  they  pass  into  the  pulmonary  artery  and  are  finally  deposited 
into  the  lungs.  The  discussion  of  the  disturbances  which  may  result  from 
displaced  portions  of  thrombi  vill  be  found  in  the  paragraph  on  embolism. 

Venous  Stasis  and  Its  Consequences.— Obliteration  of  the  lumen 
of  a  vein  either  by  ligation  or  by  pressure  from  neighboring  inflammatory 
conditions  or  neoplasms,  unless  the  collateral  circulation  is  established  at  once, 
produces  decided  disturbances  in  the  capillary  area  from  w^hich  the  obstructed 
vein  receives  blood.  The  changes  which  occur,  this  description  being  based 
on  observations  of  the  process  as  it  takes  place  in  the  web  of  the  frog's  foot  on 
the  stage  of  the  microscope,  are  as  follows:  The  smaller  veins  and  capillaries 
become  filled  to  their  utmost  capacity;  the  arteries  continue  to  supply  blood 
to  these,  its  escape,  however,  being  prevented  by  the  obstruction.  Each  sys- 
tolic heart  movement  sends  a  wave  of  impulse  into  the  already  overfilled  area, 
but  in  the  intervals  of  diastolic  pause  between  the  heart-beats  this  wave  of 
impulse  recedes  in  the  capillary  area.  The  effect  of  this  is  to  give  a  to-and-fro 
movement  of  the  blood-corpuscles.  This  wave  results  from  the  fact  that  \vhen 
the  increased  tension  on  the  somewhat  elastic  vessels  is  lessened  by  the 
relaxation  of  the  heart  muscle  (diastole) ,  these  force  some  of  their  contents  back 
against  the  arterial  column.  After  twenty-four  hours  or  less  of  this  fruitless 
effort  on  the  part  of  the  arterial  current  to  force  the  blood  through  the  capil- 
laries, the  watery  constituents  of  the  blood  are  forced  through  the  vessel  walls 
and  into  the  perivascular  spaces.  At  the  same  time  the  red  blood-corpuscles 
are  forced  through  the  avails  of  the  vessels  in  greater  or  lesser  quantity,  and 
diapedesis  of  the  red  blood-corpuscles  occurs  (Cohnheim).  Coin- 
cidentally  the  capillaries  increase  greatly  in  size.  The  escape  of  the  blood- 
serum  into  the  tissues  resulting  from  the  permanent  pressure  exerted  by  the 
arterial  column  causes  the  red  blood-corpuscles  to  accumulate  in  a  homogene- 


104  INJURIES   AND   DISEASES   OF  SEPARATE  TISSUES 

ous  mass,  in  which  the  individual  corpuscles  can  no  longer  be  recognized. 
Those  which  have  escaped  through  the  vessel  wall,  however,  may  be  seen  lying 
in  the  perivascular  spaces.  The  view  that  hemorrhage  by  diapedesis  occurred 
was  held  by  the  older  writers,  but  subsequently  denied,  the  theory  being 
rejected  in  favor  of  hemorrhage  by  rupture  of  the  vessel  as  the  exclusive 
method  of  escape  of  the  red  blood-corpuscles. 

If  the  pressure  continues  to  obstruct  the  circulation,  whether  this  occurs 
from  the  application  of  a  ligature,  as  in  Cohnheim's  experiments, 
or  from  the  pressure  of  a  neoplasm  or  inflammatory  processes,  the  senim  is 
forced  from  the  interior  of  the  vessels  into  the  perivascular  spaces,  and  the 
condition  known  as  edema  results.  The  pressure  being  continued,  the  serum 
is  forced  into  the  rete  Malpighii,  and  blebs  or  blisters  may  thus  arise  in  venous 
stasis.  The  slightly  reddish  or  deep  straw  color  of  their  contents  is  due  to 
the  presence  of  greater  or  lesser  numbers  of  the  migrated  red  blood-corpuscles; 
in  less  severe  cases  the  fluid  is  identical  with  pure  blood-serum.  In  extreme 
and  rapidly  occurring  cases  of  venous  stasis  the  migrated  red  blood-corpuscles 
in  the  connective- tissue  spaces  may  be  grouped  together;  usually,  however, 
they  occur  in  this  situation  singly.  Generally  speaking,  there  is  to  some 
extent  a  collateral  circulation  established,  which  permits  of  a  somewhat 
impaired  but  sufficient  return  of  the  venous  blood  from  the  affected  area  to 
the  blood-current. 

The  diagnosis  of  venous  stasis  resulting  in  edema  is  made  by  the  presence 
of  the  characteristic  objective  sign  of  the  latter,  namely,  pitting  on  pressure. 
The  finger  being  pressed  firmly  against  the  soft  swelling  at  the  site  of  the  edema, 
its  removal  will  show  the  impression  left  in  the  tissues,  which  disappears  again 
in  a  few  seconds.  By  this  manipulation  the  serum  is  pressed  into  the  neigh- 
boring connective-tissue  spaces,  and  perhaps  also  into  the  lymph- vessels. 
There  may  occur  conditions  of  edema  in  which  pitting  is  not  produced,  on 
account  of  extreme  tension  of  the  skin  and  connective  tissue.  The  distinction 
between  edema  and  inflammatory  swelling  will  be  made  clearer  by  attention 
to  the  following  points:  In  edema  the  fluid  which  accumulates  in  the  tissue 
is  light  straw-colored  serum  in  mild  cases,  and  reddish  colored  in  severe  cases; 
in  inflammation  this  fluid  is  plastic  lymph  in  serous  inflammation,  and  pus  in 
suppurative  inflammation.  In  edema  the  blood  is  at  a  standstill,  while  in 
inflammation  it  circulates  through  the  dilated  vessels.  In  edema  the  cellular 
elements  found  in  the  perivascular  spaces  are  exclusively  the  red  blood- 
corpuscles;  in  inflammation  these  cellular  elements  consist  of  white  blood- 
corpuscles.  In  edema  the  swelling  is  marked  by  a  local  normal  or  sub- 
normal temperature;  in  inflammation  the  swelling  is  accompanied  l)y  a  local 
elevation  of  temperature. 

Venous  stasis  in  small  as  well  as  in  large  vessels  may  result  from  ob- 
struction. This  occurs  more  particularly  in  inflammatory  processes,  the  return 
circulation  being  interrupted  in  several  veins  at  once,  and  thus  the  establish- 
ment of  a  collateral  circulation  is  prevented.  In  small  veins  the  obstruction 
may  result  from  the  filling  of  their  lumina  with  white  bloocl-corpuscles,  the 
so-called  white  thrombus,  or  from  the  filling  of  these  wath  pus.  Here  the 
symptoms  of  venous  stasis  and  inflammation  occur  conjointly. 

The  most  constant  as  well  as  the  most  important  sequence  of  persistent 
venous  stasis  is  that  condition  of  the  involved  area  of  distribution  known  as  gan- 


INJURIES    AND    DISEASES    OF    BLOOD-VESSELS  105 

grene.  Coagulation  of  the  blood  in  extensive  capillarv  regions  extending  into 
the  small  arteries  leads  to  the  death  of  circumscribed  areas,  as,  for  instance, 
that  of  portions  of  the  foot  and  leg  after  injury  and  thrombosis  of  the  femoral 
artery.  The  gangrene  which  follows  burns  of  the  third  degree  is  partly  the 
result  of  venous  stasis.  The  abundance  of  fluid  in  the  parts,  due  to  the 
increased  quantit}^  of  blood  massed  within  the  region  implicated,  together 
with  the  edematous  condition  present,  shows  a  more  or  less  strongly  marked 
contrast  to  the  gangrene  which  follows  obstruction  of  the  arterial  trunks 
(embolic  gangrene).  Because  of  these  differences  the  former  is  designated 
as  moist  and  the  latter  as  dry  gangrene.  Although  hi  the  latter  an  edem- 
atous condition  does  not  occur,  yet  this  discrimination  is  not  quite  exact; 
while  in  embolic  gangrene  the  peripheral  portions  are  comparatively  blood- 
less in  the  beginning,  yet  blood  is  finally  supplied,  sometimes  in  a  very 
short  time,  and  the  parts  are  plentifully  saturated  with  moisture.  The  in- 
vasion of  the  parts  by  micro-organisms  is  a  very  important  part  of  the 
process  in  gangrene,  and  the  appearance  of  these  sooner  or  later  not  only 
originates  and  hastens  the  more  or  less  rapid  putrefaction  of  the  devital- 
ized tissues,  but  produces  gangrenous  inflammation  of  the  adjoining  living 
structures. 

In  the  treatment  of  venous  stasis  the  first  care  of  the  surgeon  is  to  place  the 
limb  in  which  it  occurs  on  a  higher  level  than  the  horizontal,  in  order  to  aid, 
by  force  of  gravity,  the  return  flow  of  blood  from  the  tissues,  and  to  avert  the 
more  serious  consequences  which  may  result  from  this  condition.  Ever}'  effort 
should  be  made  to  give  the  collateral  channels  time  to  dilate  and  thus  perform 
vicariously  the  function  of  the  obstructed  veins.  In  this  manner  only  can 
extensive  gangrene  and  edema  be  prevented.  Centripetally  apphecl  friction 
movements  or  massage  may  be  useful,  but  care  should  be  exercised  in  the 
application  of  this,  for  the  reason  that,  though  its  usefulness  in  promoting 
reflux  of  blood  and  lymphatic  absorption  is  well  established,  it  may  do  harm, 
if  applied  in  the  immediate  vicinity  of  the  vein  which  is  the  seat  of  the  throm- 
bosis, by  forcing  into  the  circulation  loosened  masses  of  coagula,  dangerous 
embolism  resulting. 

Gangrene  following  venous  stasis  is  a  most  serious  condition  and 
demands  the  utmost  watchfulness  on  the  part  of  the  surgeon.  The  fact  should 
be  borne  in  mind  that  early  and  extensive  infection  from  exposure  to  bac- 
terial influence  is  very  likely  to  occur.  Early  provision  should  be  made 
to  prevent  this,  and  to  hmit  it  if  it  has  already  occurred.  The  parts 
should  be  protected  as  far  as  possible  by  means  of  a  1  :  1000  solution  of 
sublimate.  The  repeated  application  of  crude  pyroligneous  acid  (Sim- 
mons), from  which  the  acetic  acid  of  commerce  is  obtained,  or  diluted  acetic 
acid,  is  useful  as  an  antiseptic  and  stimulant  application,  particularly  where 
the  entire  limb  is  involved.  By  these  measures  putrefaction  may  be  some- 
times prevented,  the  dead  mass  becoming  mummified.  Immediately  on  the 
appearance  of  the  line  of  demarcation  separating  the  dead  from  the  living 
tissues,  and  under  some  circumstances  even  before  this,  amputation  of  the 
limb  should  be  performed.  Patients  not  infrequently  succumb  to  meta- 
static pyemia,  in  spite  of  every  effort. 

Embolism. — Embolic  processes,  to  which  frequent  references  have  been 
made  in  the  preceding  paragraphs  in  connection  with  the  transportation  of 


106  INJURIES    AXD    DISEASES    OF    SEPARATE    TISSUES 

corpuscular  elements,  portions  of  fatty  or  calcareous  degenerated  arterial 
intima,  or  of  decomposed  thrombi,  may  be  divided  for  purposes  of  study  into 
two  groups.  In  the  first  of  these  the  embolus  originates  from  the  left  heart  or 
some  portion  of  the  arterial  trunk  system;  the  second  includes  those  cases  in 
which  intravenous  thrombi  furnish  the  material.  Of  the  first-named  group, 
surgically  speaking,  the  most  important  conditions  are  those  which  include 
embolic  gangrene  of  the  lower  extremities,  particularly  that  of  the  toes,  foot, 
and  leg,  the  so-called  senile  gangrene.  In  the  second  group  the  emboli  are 
derived  from  the  small  veins  and  are  forced  by  the  return  circulation  into  the 
large  veins,  or  are  formed  in  the  latter,  and  portions  thereof  are  carried  into 
the  venous  trunks.  In  either  event  they  are  usually  carried  to  the  right 
heart  and  thence  into  the  pulmonaiy  circulation.  Here,  as  a  rule,  they  lodge, 
though  smaller  emboli  containing  infectious  material  may  pass  through  the 
puhnonarv'  artery  and  its  branches,  and  gain  access  to  the  general  arterial 
circulation. 

The  immediate  result  of  the  arrest  of  an  embolus  derived  from  an  endar- 
teritis is  the  filling  of  the  vessel  in  which  it  lodges,  and  which  is  thus  plugged 
(obstructive  embolus).  The  area  of  distribution  of  the  obstructed  vessel, 
in  the  absence  of  an  immediate^  established  collateral  circulation,  is  at  once 
deprived  of  its  blood-supply.  The  failure  of  the  collateral  circulation  may 
be  due  to  an  endarteritis  deformans  in  the  neighboring  vessels  which  prevents 
them  from  supplying  the  requisite  amount  of  blood,  or  to  a  weakened  circula- 
tion in  feeble  individuals,  or  to  both.  Xecrosis  of  the  starved-out  area  super- 
venes, and  the  condition  kno-wai  as  embolic  infarction  follows.  These  infarc- 
tions are  usualh'  wedge-shaped,  the  base  of  the  wedge  corresponding  to  the 
first  ramification  of  the  vessels,  while  its  point  lies  in  the  direction  of  the 
obstructed  arterj^  (cuneiform  infarctions). 

A  capillary  hemorrhage  about  an  infarction  sometimes  occurs,  and  for 
a  long  time  it  was  thought  that  this  was  the  primary  condition,  and  not  the 
result  of  the  embolic  infarction.  The  true  explanation  of  its  occurrence  is 
as  follows:  The  anemic  condition  of  the  excluded  area  havmg  existed  for  a 
short  time,  the  capillaries  in  the  neighborhood,  in  response  to  the  augmented 
blood-pressure,  dilate  and  send  arterial  blood  into  the  former,  through 
numerous  anastomoses.  The  obstruction  which  the  blood  meets  in  its  attempts 
to  permeate  the  infarction  leads  to  stasis  within  these  dilated  arterioles 
(hyaline  thrombi,  Recklinghausen),  still  further  impeding  its 
progress,  and  the  red  blood-corpuscles  are  forced  through  the  wall  of  the  vessel. 
These  capillary  hemorrhages  are  found  in  situations  where  the  blood-supply 
is  particularly  rich  and  the  freest  anastomoses  exist  (lungs  and  spleen) ;  on 
the  other  hand,  where  these  conditions  do  not  obtain,  infarctions  occur  with- 
out capillary  hemorrhages  (kidne}^  and  brain). 

In  addition  to  the  mechanic  effects  of  embolism,  this  condition  is  hke- 
wise  of  importance  in  connection  with  the  transportation  and  deposit  of  infec- 
tious material  at  the  points  of  obstruction,  or  where  emboU  become  adherent; 
here  new  colonies  of  bacteria  develop  in  consequence.  This,  the  infectious 
embolus,  it  is  believed,  becomes  the  bearer  not  onh-  of  pathogenic  germs 
(see  Pyemia)  in  the  ordinary  sense  of  the  term,  but  likewise  of  the  cell- 
elements  of  certain  malignant  tumors. 


LY-AIPHATIC    VESSELS    AND    LYMPHATIC    GLAXDS  107 

INJURIES  AND  DISEASES  OF  THE  LYMPHATIC  VESSELS 
AND  LYMPHATIC  GLANDS 

Injuries  of  Lymph=vessels.— Any  injury  of  the  soft  parts  necessarily 
invoh-cs  injur}-  of  the  lymphatic  vessels.  The  walls  of  these  are  so  attenuated 
and  their  lumina  so  small  as  to  escape  notice.  The  escape  of  lymph  is  so 
slight  that  it  is  masked  by  the  flow  of  blood.  Some  hours  afterward,  however, 
this  is  noticeable  as  a  part  of  the  wound  secretion,  which  is  composed  of  lymph, 
connective-tissue  fluid,  and  blood-serum,  originating  from  the  vessels  mvolved 
in  the  venous  stasis.  In  some  situations,  however,  such  an  amount  of  lymph 
ma}'  escape  as  to  constitute  a  genuine  lymphorrhagia.  notably  in  the  axilla 
and  inguinal  region,  where  the  principal  lymph-vessels  of  the  extremities  join 
those  of  the  trunk. 

Contusions  in  situations  where  the  muscular  structures  are  closely  adja- 
cent to  the  skin  may  result  in  a  rupture  of  a  sufficient  number  of  lymph- 
A-essels  to  constitute  a  subcutaneous  lymphorrhagia.  Most  of  the  reported 
cases  of  this  condition  have  occuiTed  in  the  lumbar  region,  and  have  resulted 
from  the  contact  of  some  hea\^'  object  with  the  body,  the  force  being  applied 
in  a  slanting  chrection.  As  pathognomonic  signs  are  to  be  mentioned  the 
following:  (1)  well-marked  fluctuation  immediately  occurs,  and  persists, 
inasmuch  as  the  contents  of  the  swelling  do  not  become  solidified;  (2)  the 
exploring  trocar  demonstrates  the  presence  of  a  clear,  shghtly  yellow  fluid;  (3) 
jDain  and  febrile  action  are  generally  absent. 

The  prognosis  is  favorable.  The  treatment  consists  in  the  apphcation 
of  a  pressure  bandage.  Should  the  condition  persist  and  require  operative 
mterference,  especially  careful  aseptic  measures  should  be  taken,  for  the  reason 
that  even  shght  infection  under  these  circumstances  may  lead  to  -widespread 
septic  conditions. 

Injury  of  the  Thoracic  Duct.— The  thoracic  duct  may  be  injured  opera- 
tively  in  the  neck,  and  by  gunshot  and  stab  wounds  in  this  situation  and  in 
the  thorax.  Operative  injuries  are  recognized  by  a  copious  flow  of  milky  fluid 
during  digestion,  which  coagulates  spontaneously  when  exposed  to  the  au-, 
and  of  clear  fluid  during  fasting.  Intrathoracic  injuries  of  the  duct  usually 
lead  to  accumulations  of  chylous  fluid  in  the  pleural  cavity,  and  are  frequently 
fatal  through  inanition. 

The  prognosis  in  operative  cases  is  more  favorable  (14  recoveries  in  15 
cases,  Allen  and  Briggs).  The  treatment  consists  in  compression, 
which  is  usually  successful.  Ligation  of  the  distal  end  may  be  attempted; 
a  pair  of  valves  on  the  proximal  end  stops  the  flow  of  chyle  from  that  chrec- 
tion.    A  collateral  circulation  is  usually  established. 

Obstruction  of  the  Thoracic  Duct. — This  may  arise  from  the  pressure  of 
tumors  from  within,  or  from  growths  springing  from  the  Avails  of  the  duct.  It 
may  also  have  its  origin  in  inflammatory'  conditions  of  the  duct  leading  to 
stricture,  and  in  impaction  of  filaria.  Thrombosis  of  the  left  innominate 
vein,  or  of  the  duct  itself,  and  the  backward  pressure  of  blood  in  the  sub- 
clavian vein  in  cases  of  tricuspid  insufficiency,  may  also  cause  obstruction. 
When  the  obstruction  is  in  the  lower  part  of  the  duct,  it  is  usuaUy  compensated 
for  by  the  establishment  of  a  collateral  circulation.  This  failing,  general  lymph- 
angiectasis  may  follow.     Transudation  of  chyle  or  its  escape  from  ruptm-e  of 


108  INJURIES   AND    DISEASES   OF   SEPARATE   TISSUES 

the  duct  leads  to  infiltration  of  the  tissues.  Or,  the  chylous  fluid  may  collect 
in  the  cavity  of  the  peritoneum  (chylous  ascites)  or  in  the  pleural  cavity. 

Normal  lymphatic  glands  arc  not,  as  a  rule,  visible  in  wounds  or  during 
operations,  on  account  of  their  very  small  size.  Under  certain  pathologic 
conditions,  as,  for  instance,  in  the  presence  of  certain  neoplasms  rec[uiring 
operative  interference,  these  glands  are  removed  when  discernible.  The  part 
Avhich  these  structures  play  in  the  removal  of  effused  blood  after  subcutaneous 
injuries  is  an  important  one.  Red  blood-corpuscles,  in  the  course  of  this 
resorptive  process,  are  carried  by  the  lymph-current  to  the  reticulum  of 
the  lymphatic  glands  and  accumulate  within  them  (vide  infra). 

Inflammation  of  Lymph=vessels  (Lymphangitis). — The  relation  of  the 
lymphatic  radicles  to  the  pathologically  altered  current  in  cases  of  inflam- 
matory processes  permits  the  admission  into  these  of  free  bacteria,  as  Avell 
as  of  those  inclosed  in  cells.  The  lymph-current  may  become  obstructed  in 
the  radicles  by  the  corpuscular  elements  added  to  the  hmiph,  or  these  may  be 
carried  on  to  the  next  adjacent  lymphatic  glands ;  the  latter  condition  occurs  in 
the  majoritA^  of  cases.  The  blood-corpuscles  carrv  the  infectious  material,  and 
act  to  obstruct  the  current.  The  role  which  they  play  in  inflammatory^  pro- 
cesses is  therefore  a  twofold  one:  (1)  they  may  transport  agents  to  distant 
parts;  or  (2)  they  may  themselves  become  infected  from  contact  with  infec- 
tious material.  Or,  what  happens  more  frec[uently,  the  nearest  lymphatic 
glands  become  infected.  Inflammation  of  the  lymphatic  channels  speedily 
follows  this  infection,  and  lymphangitis  is  the  result.  If  this  occurs  in  the 
radicles,  it  is  knoAMi  as  reticular  lymphangitis,  and  if  in  the  tnmks,  as 
tubular  lymphangitis.  The  first-named  form  of  the  disease  consists  of  a  cir- 
cumscribed patch  of  reddened  and  edematous  skin,  and  is  frec^uently  seen  in  the 
neighborhood  of  a  focus  of  infection  (erysipeloid  of  R  o  s  e  n  b  a  c  h).  which 
may  persist  and  even  be  propagated  after  the  entire  disappearance  of  the 
primary-  infection.  This  is  the  variety  usually  present  in  instances  of  some- 
what mild  infection,  though  it  may  be  seen  in  connection  with  a  virulent 
infection  as  well,  in  which  case  it  is  soon  followed  by  the  tubular  variety.  In 
er\'sipeloid  or  reticular  lymphangitis  it  has  been  thought  that  a  specific  spore- 
bearing  organism,  derived  from  decomposing  animal  matter,  was  the  cause 
of  the  inflammation  (R  o  s  e  n  b  a  c  h)  .  The  presence  of  the  bacteria,  what- 
ever their  form,  within  the  lymph-channels,  particularly  those  which  cling 
to  the  walls  of  the  radicles,  produces  coagulation  and  consec[uent  formation  of 
thrombi.  These  inclose  bacteria  which,  in  their  turn,  infect  the  thin  Avails  of 
the  lymph-vessel,  and  through  these  the  surrounding  connectiA'e  tissue.  In 
this  manner  a  reticular  lymphangitis  and  cellulitis  are  combined;  this  is  the 
form  most  commonly  obserA'ed,  and  constitutes  a  form  of  er\'sipelatous 
inflammation;  it  is  due  to  theiuA-asion  of  the  lymph-channels,  either  from  a 
Avouncl  surface  or  through  a  sweat-gland  or  hair-follicle,  by  Streptococcus 
erysipelatis  (see  page  27).  A  more  than  usually  A'irulent  form  of  infection 
causes  rapid  spread  of  the  inflammation,  and  a  tubular  lymphangitis  is  present. 
Here  the  thrombi,  A\-hen  superficially  situated,  ma}-  be  perceptible  to  the  touch 
as  a  hard  cord;  the  connectiA'e  tissue  of  the  sheath  of  the  lymph- A'-essel 
becomes  early  infected  and  inflamed,  and  the  red  stripe  or  streak  Avhich  is  then 
obserA-ed  serA-es  to  identify  positiA^ely  the  seat  of  the  disease.  A  number  of 
these  thrombosed  lymph-A-essels,  Avith  their  accompanying  periA^ascular  stripes, 


LYMPHATIC   VESSELS   AND    LYMPHATIC   GLANDS  109 

are  observed  ninnins;  parallel  to  one  another,  and  extending  from  the  reticular 
form  immediately  adjacent  to  the  primary  focus  to  a  considerable  distance 
in  a  centripetal  direction.  In  case  a  considerable  number  of  lymph-channels 
are  involved,  lymphostasis  occurs,  and  a  certain  amount  of  edema  complicates 
the  already  existing  inflammatory  swelling. 

The  formation  of  thrombi  in  lymph-channels  differs  essentiall}'  from  that 
which  occurs  in  blood-vessels  (page  102),  dependent,  as  it  is,  on  the  inflam- 
mator}^  process  itself,  and  resulting  from  the  excessix^e  entrance  of  bacteria 
within  the  lymph-vessels,  whereby  a  rapid  extension  of  the  disease  is  caused. 
Despite  this,  however,  these  thrombi  are  more  rapidly  resorbed  than  those  which 
occur  as  intra-arterial  and  intravenous  thrombi,  for  the  reason  that  they  are 
in  intimate  relation,  on  all  sides,  with  resorbing  collateral  lymph-channels. 
This  is  the  usual  method  of  their  disappearance.  Exceptionally  suppurative 
inflammation  and  the  formation  of  abscess  occur;  when  this  happens,  the 
abscesses  are  usually  seen  in  circumscribed  areas,  and  quite  commonly,  singly 
as  well.  The  strip  of  redness  at  the  site  of  the  lymphangitis  enlarges,  and 
finally  a  fluctuating  swelling  appears.  It  is  questionable  if  so-called  organiza- 
tion of  these  thrombi  ever  occurs.  Certain!}'  cicatricial  development  in  the 
connective  tissue  along  the  hne  of  the  previously  involved  h^mphatic  vessel  has 
never  been  demonstrated. 

The  prognosis  is  not  particularly  affected  by  the  formation  of  an  abscess 
in  the  course  of  a  lymphangitis,  as  compared  with  the  dangers  which  arise  from 
suppurative  inflammation  in  wounds.  On  the  contrary,  a  rather  favorable 
influence  may  be  exercised  by  the  formation  of  abscesses  under  these  circum- 
stances, as  these  are  quickly  circumscribed  and  form  a  ready  means  of  elimi- 
nating the  infective  agents  which  ha^^e  found  entrance  into  the  h-mph- 
channels. 

In  the  treatment  of  lymphangitis  the  one  thing  to  be  borne  in  mind  is  the 
fact  that  its  extension  depends  on  the  combined  presence  of  septic  agents  and 
open  lymph-channels.  The  treatment,  therefore,  must  be  of  the  most  rigid 
antiseptic  character.  Fortunately  the  open  lymph-channels  form  a  ready 
means  for  the  introduction  of  antiseptic  agents  into  the  region  of  infection. 
When  the  wound  cavity  can  be  reached,  if  the  disease  is  the  result  of  a  wound 
which  has  become  infected,  this  should  be  thoroughly  packed  with  gauze, 
saturated  either  ^^•ith  a  2.5  to  5  per  cent  solution  of  carbolic  acid,  or  vith  a 
1:2000  solution  of  corrosive  sublimate  in  50  per  cent  alcohol.  The  best 
application  to  the  reddened  patch  of  reticular  lymphangitis,  or  the  stripes  of 
tubular  lymphangitis,  is  a  large  compress  wrung  out  of  the  carbolic  acid 
solution.  The  addition  of  tincture  of  opium,  in  the  proportion  of  an  ounce  to  a 
pint,  to  the  solution,  and  the  application  of  an  oiled  silk  covering  to  the  com- 
press will  be  found  useful.  As  soon  as  the  more  acute  symptoms  have  sub- 
sided, the  use  of  mercurial  ointment  along  the  lines  of  thrombi  is  indicated; 
in  the  reticular  variety  a  20  per  cent  mixture  of  ichthyol  in  lanolin  is  very  use- 
ful, locally  applied.  Abscess  cavities  along  the  course  of  the  l3'mph-vessels 
should  be  opened  freely  and  treated  antiseptically. 

No  danger  is  to  be  apprehended  from  displacement  of  lymph  thrombi. 
Even  should  this  occur,  they  would  be  arrested  in  the  nearest  lymphatic  gland. 

Inflammation  of  Lymphatic  Glands  (Lymphadenitis). — The  rela- 
tions between  the    lymphatic  vessels  and    the   lymphatic    glands   are    such 


110  INJURIES    AND    DISEASES    OF    SEPARATE    TISSUES 

as  to  render  the  latter  liable  to  become  involved  in  inflammatory  condi- 
tions of  the  former.  The  extent  to  which  this  occurs,  however,  will  be  in 
inverse  ratio  to  the  intensity  of  the  lymphangitis.  The  reason  for  this  is 
obvious.  With  a  high  degree  of  inflammation  thrombi  form  rapidly  and  the 
lymph-channels  become  early  obliterated,  while  in  a  mild  or  lesser  degree  of 
infection  the  bacteria  will  reach  the  lymphatic  glands  without  meeting  Avith 
great  obstruction.  The  physiologic  function  of  the  lymphatic  glands  favors- 
the  accumulation  within  their  structure  of  such  matter  of  a  foreign  character, 
whether  bacterial  or  corpuscular  elements,  as  may  find  its  way  into  the  lymph- 
current.  The  extent  to  which  this  may  become  infected  will  depend  on  the 
intensity  of  the  infection ;  this  may  be  of  every  grade  of  severity,  the  resulting 
inflammation  ranging  from  a  slight  tumefaction  and  tenderness  to  a  rapid 
breaking  down  and  suppuration.  Chronic  enlargement  and  induration  are  not 
infrequently  observed,  this  condition  remaining  for  years  without  apparently 
affecting  the  health  of  the  individual. 

The  swelling  which  occurs  in  lymphadenitis  is  due  to  the  migration  of  white 
corpuscles  to  the  cortex  of  the  gland,  and  the  accumulation  of  lymph  and  the 
formation  of  thrombi  in  the  gland  structure.  Besides  this,  there  is  a  direct 
inflammatory  proliferation  of  the  lymph-cells,  equivalent  to  the  migration  of 
the  white  blood-corpuscles,  which  are  transformed  directly  into  pus-corpuscles. 

Suppuration  may  follow,  an  abscess  of  the  gland  resulting.  This  may  occur 
when  there  has  been  no  suppuration  at  the  point  of  original  infection,  as  not 
infrequently  happens  in  cases  of  infected  wounds  of  the  fingers.  Again,  granu- 
lating inflammation  (syphilitic,  tuberculous,  etc.)  may  give  rise  to  secondary 
lymphadenitis  by  infection  Avhen  no  suppuration  has  occurred  at  the  site  of  the 
inflammation  itself. 

Suppuration  of  the  glands  may  happen  early,  or  a  slow  breaking  down  may 
occur.  A  single  gland  is  rarely  involved,  usually  the  process  including  a  con- 
glomerate mass  consisting  of  several  glands.  The  capsule  of  the  gland  is  in- 
volved in  the  suppurative  process,  the  latter  passing  thence  to  the  surround- 
ing connective  tissue  (paradenitis),  this  being  an  incident  in  the  course  of  an 
unusually  severe  lymphadenitis.  This  condition  of  paradenitis  may  mask  the 
glandular  inflammation  to  some  extent,  and  may  partake  somewhat  of  the 
characteristics  of  a  phlegmonous  inflammation,  particularly  when  it  occurs  in 
the  loose  connective  tissue  of  the  neck.  Or,  abscesses  may  occur  in  the  tissue 
outside  the  gland,  the  latter,  enlarged  and  infiltrated,  lying  in  the  cavity  yet  not 
itself  involved  in  the  suppurative  process.  Again,  the  gland  may  first  become 
the  site  of  suppurative  inflammation  to  a  limited  extent,  the  pus  from  which 
finds  its  way  into  the  connective  tissue  outside  the  gland,  and  collects  there, 
and,  by  a  process  of  ulceration,  points  toward  the  surface.  If  not  evacuated, 
it  finds  its  way  out,  and  a  fistulous  communication  is  established  leading  into 
the  gland.  The  skin  about  these  fistulous  openings  is  usually  adherent  to  the 
gland  structure  underneath,  and  becomes  extremely  thin  from  atrophy  due  to 
pressure  and  the  suppurative  process  going  on  in  the  deeper  layers  of  the  skin. 
It  becomes  quite  blue  in  color,  and  is  very  likely  to  slough  if  it  is  made  use 
of  as  a  flap  in  the  operation  for  the  removal  of  these  infected  glands.  The 
skin  will  be  found  to  be  loosened  here  and  there  from  the  underlying  mass, 
the  center  of  this  undermined  portion  corresponding  to  the  site  of  a  fistula, 
of  which  there  mav  be  several  leading  to  the  same  mass. 


LYMPHATIC    VESSELS    AND    LYMPHATIC    GLANDS  111 

In  the  treatment  of  simple  lymphadenitis,  in  case  the  point  of  infection 
can  be  reached,  the  rational  j^rocedure  consists  of  the  application  of  antiseptic 
measures  in  such  a  manner  as  to  destroy  the  primary  focus.  As  a  rule,  how- 
ever, this  will  not  be  discoverable.  The  treatment  under  these  circumstances 
will,  therefore,  be  very  unsatisfactory.  The  injection  of  carbolic  acid  or  of 
chlorid  of  zinc  solutions  into  the  inflamed  glands  has  not  been  followed  by  very 
brilliant  results.  The  same  may  be  said  of  applications  and  injections  of  tinc- 
ture of  iodin. 

As  soon  as  an  abscess  forms  it  should  be  opened  freely.  As  a  rule,  the  entire 
glandular  tissue,  though  diseased,  is  not  involved  in  the  suppurative  process. 
If  the  abscess  cavity  is  simply  opened,  under  these  circumstances,  incomplete 
healing,  or  at  any  rate  a  very  tedious  convalescence,  may  be  expected.  The 
propei;  course  to  pursue  is  to  remove  thoroughly,  with  either  the  knife  or  the 
curet,  any  portion  of  diseased  glandular  tissue  within  reach.  The  fistulas, 
which  are  so  frequently  observed  after  spontaneous  or  incomplete  opening 
of  an  abscess  from  lymphadenitis,  should  all  be  thoroughly  incised  and  the 
curet  employed  to  curet  out  their  walls,  and  diseased  gland  tissue  as  well. 
Skin  which  has  been  undermined  is  to  be  cut  away.  The  curet  is  to  be  applied 
unsparingly  until  the  connective-tissue  covering  is  reached,  when  healthy  granu- 
lations and  complete  healing  may  be  confidently  anticipated.  This  may  be 
hastened  and  a  better  cosmetic  result  obtained  by  skin-grafting. 

Tuberculous  Lymphadenitis.— The  chronic  granulating  and  caseating 
inflammations  of  the  lymphatic  glands  which  go  to  make  up  the  general  picture 
of  tul^erculous  lymphadenitis  form  one  of  the  most  important  diseases  to  which 
these  structures  are  subject.  The  infective  agent  almost  invariably  enters  by 
way  of  the  lymph-channels  from  some  peripheral  tuberculous  focus.  Tuber- 
culous lymphadenitis  frequently  follows  the  so-called  scrofulous  inflammations 
of  the  skin  and  mucous  membrane,  such  as  chronic  moist  eczema  of  the  face 
and  scalp,  chronic  catarrhal  inflammation  of  the  conjunctiva,  the  middle  and 
external  ear,  the  mucous  membrane  of  the  nose  and  jiharynx,  etc.  This 
accounts  for  the  frequent  occ\irrence  of  tuberculous  inflammation  of  the  glands 
of  the  anterior  and  lateral  regions  of  the  neck.  The  conjoint  or  sequential 
occurrences  of  these  last-named  conditions  go  to  make  up  the  state  formerly 
known  under  the  name  of  "scrofula." 

Glands  in  other  regions  of  the  body  likewise  become  the  subject  of  secondary 
tuberculous  deposits,  such,  for  instance,  as  those  in  the  axilla  which  follow 
tuberculous  affections  of  the  skin,  bones,  and  joints  of  the  upper  extremity 
and  those  in  the  inguinal  region  which  follow  like  conditions  in  the  lower  ex- 
tremity, and  the  genital  organs ;  the  glands  situated  in  the  ischiorectal  region 
following  tuberculous  disease  of  the  lower  bowel,  or  of  the  skin  in  the  anal 
region  (see  Fistula  in  Ano) ;  the  peribronchial  glands  in  pulmonary  tuberculosis, 
and  the  mesenteric  and  retroperitoneal  glands  in  tuberculous  enteritis. 

Lymphatic  glands  the  site  of  tuberculous  infection  may  either  undergo 
rapid  suppurative  changes  and  cheesy  metamorphosis,  or  may  remain  for  a 
long  time  as  soft  semi-elastic  swellings,  which  are  freely  movable  under  the 
skin.  In  the  first  named  the  products  of  suppuration  collect  in  the  capsule 
of  the  gland,  a  paradenitis  follows,  and  the  pus  finally  makes  its  way  toward 
the  surface,  emptying  itself  through  fistulous  openings  on  the  skin.  The 
second  breaks  down  late,  if  at  all,  and   cheesy  foci  are  likewise  observed 


112  INJURIES    AND    DISEASES    OF    SEPARATE    TISSUES 

late  in  the  course  of  the  disease.  The  glands  crowd  closel}'  together  in 
this  form  and  sometimes  attain  the  size  of  a  hen's  or  a  goose's  egg.  On 
section  they  present  a  grayish  diaphanous  appearance;  their  structure  breaks 
down  easily  under  the  finger,  and  somewhat  resembles  the  contents  of  the 
medullary  cavities  of  the  long  bones,  although   it  is  somewhat  firmer. 

Microscopic  examination  of  the  first  form  shows  infiltration  of  small  cells, 
composed  of  migrating  leukocytes  and  newly  formed  lymphoid  cells.  Between 
these  areas  of  infiltration,  foci  of  suppuration  and  cheesy  degeneration  are 
found.  This  is  the  variety  which  affects  children  principally.  The  second 
form,  that  in  which  an  apparent  quiescent  state  is  maintained,  is  the  tubercu- 
lous lymphadenitis  of  adolescence;  this  appears  by  preference  in  the  cervical 
and  axillary  glands. 

As  regards  general  or  distant  infection,  the  prognosis  in  the  latter  form  is 
much  more  favorable  than  in  the  former.  In  the  one  the  tuberculous  agent  is 
localized  for  a  long  time,  perhaps  permanent^,  while  in  the  other,  or  in  that 
w^hich  affects  children,  the  early  suppuration  and  caseation  lead  to  disintegra- 
tion and  ready  transportation  of  infective  agents  to  distant  parts. 

Treatment. — As  long  as  these  glandular  structures  remain  without  break- 
ing down  into  suppuration  or  undergoing  caseation,  comparatively  slight  dan- 
ger attends  their  presence.  The  difficulty,  however,  is  that  the  surgeon  cannot 
tell  just  when  either  of  these  processes  may  be  initiated,  or  what  circum- 
stances will  hasten  their  development.  A  strict  surveillance  should  be  main- 
tained, and,  in  case  palpation  reveals  any  tendency  on  the  part  of  the  glands 
to  break  down,  they  should  be  extirpated  at  once.  Their  long  persistence  in  an 
apparently  unchanged  condition  will  awaken  suspicion  that  the  central  portion 
is  undergoing  cheesy  degeneration,  in  which  case  delay  in  effecting  their  removal 
may  mean  serious  peril  to  the  patient.  In  the  very  commencement  of  the  infil- 
tration, injections  of  iodin  may  be  used  with  advantage  (iodin  1,  iodid  of  potas- 
sium 4,  water  100;  Durante).  The  injections  should  be  made  daily. 
The  dose  employed  is  at  first  about  3  minims,  the  amount  being  progressively 
increased  according  to  the  size  of  the  gland  and  the  effect  produced.  Every 
portion  of  each  gland  should  receive  an  injection  in  turn,  until  all  portions 
of  the  structure  have  been  treated.  Or,  injections  of  a  5  per  cent  solution 
of  chlorid  of  zinc  into  the  structure  of  the  gland,  particularly  the  periphery 
thereof,  and  the  adjacent  structures  may  be  employed  (L  a  n  n  e  1  o  n  g  u  e) . 
The  amount  used  at  each  sitting  will  vary  from  four  to  six  drops  according 
to  the  size  of  the  gland,  at  intervals  of  from  three  to  five  days,  according  to  the 
pain  and  local  reaction  which  follows  These  measures  may  be  persisted  in 
for  several  months,  particularly  if  undoubted  improvement  follows  their 
use.  The  best  results  are  obtained  by  proceeding  slowly  and  deliberately. 
Attempts  to  hasten  the  cure  by  the  use  of  large  or  more  concentrated  solutions 
will,  by  exciting  too  great  reaction,  necessitate  abandoning  the  treatment 
altogether.  A  careful  watch  must  be  kept  for  the  breaking  down  of  the 
gland,  however,  since  the  treatment  may  have  been  begun  too  late  to  prevent 
caseation.  The  use  of  ointments  of  belladonna,  mercury,  iodid  of  potassium, 
etc.,  or  the  older  methods  of  painting  with  tincture  of  iodin,  have  now 
been  quite  generally  replaced  b}-  injection  methods  or  operative  procedures. 
Internal  medication  in  the  shape  of  ferruginous  tonics,  cod-liver  oil,  etc.,  may 
result  beneficially  by  improving  the  general  health;  this  treatment,  however. 


LYMPHATIC    VESSELS    AND    LYMl'HATIC    GLANDS  113 

should  not  take  the  j)lacc  of  tho  iiijoetion  or  operative  treatment,  but  rather 
sup,,  enient  It.  (For  the  technic  of  extirpation  of  tuberculous  Ivmphatic 
frlamls,  see  Operations  on  tho  Neck.) 

Syphilitic  Lymphadenitis.— The  infection  of  syphilis,  like  that  of  tuber- 
culous disease,  gn-cs  ri.se  to  f?ranular  inflammation  of  h-m}ihatic  o-land^  The 
ni-umal  glands,  situated  as  they  are  near  the  most  common  point  of  entrance 
of  the  mfection.  are  the  first,  as  a  rule,  to  be  involved  (see  page  197)  Other 
glands  may  likewise  become  involved,  as,  for  instance,  the  epitrochlear  and 
post-cervical  glands.  It  very  rarely  happens  that  Ivmphatic  glands  affected 
by  the  syphilitic  virus  undergo  either  suppuration  or  caseous'  degeneration 
Ihe  diagnosis  of  syphilitic  lymphadenitis  will  depend  on  the  historv 
as  to  primary  infection.  In  inquiring  into  this,  the  possibilitA'  of  nonvenereal 
infection  with  the  syphilitic  virus  should  be  borne  in  mind  '  The  prognosis 
depends  on  that  of  the  general  infection.  The  glandular  in^-ol^•ement  is 
not  such  as  to  excite  alarm.  The  treatment  will  coincide  with  the  general 
treatment  of  syphilis  (see  page  199).  The  suppuratiA-e  form  of  bubo  follow- 
ing the  venereal  sore,  known  as  the  soft  chancre  or  chancroid,  does  not 
depend  on  syphilitic  infection,  and.  therefore,  is  to  be  treated  as  a  simple  sup- 
purative lymphadenitis. 

Leukemic  Hyperplasia  of  the  Lymphatic  Qlands.-Chronic  inflamma- 
tion, or  chronic  hyperplasia  of  the  lymphatic  glands,  affecting  almost  equallv 
all  parts  of  the  gland,  lymphoid  cells,  and  reticular  structure,  accompanies  the 
disease  of  the  blood  known  as  leukemia.     This  disease  does  not  fall  within 
the  province  of  the  surgeon,  but  is  referred  to  in  this  connection  for  the  pur- 
poses of  differential  diagnosis.     The  glandular  swellings  occur  in  the  reo-ion 
of  the  neck,  axilla,  groin,  and  other  regions  to  such  an  extent  as  to  form  tumor 
masses;   the  glands  remain  freely  movable  and  discrete.     Hvperplasia  of  the 
lymphoid  tissues  of  the  body  generally  takes  place,  this  occurring  as  nodules 
m  the  mtestmes.  lixer,  and  spleen.     The  latter  mav  be  palpablv  enlarged 
increase  m  the  number  of  the  leukocytes  in  the  blood  is  the  distinguishing 
characteristic  of   the  disease,  these  sometimes   equaling  in  number  the  red 
corpuscles,  which  latter  are  generally  decreased.     The  course  of  the  disease  may 
be  slow  or  rapid ;  m  the  latter  case  an  infectious  process  is  suggested.     .Inemia 
is  a  marked  s}-mptom. 

The     diagnosis    depends    on     the     blood-examination.       Proportionate 
increase  of  the  leukocytes  in  this  disease  presents  a  marked  contrast  to  the 
absence  of  this  symptom  in  the  onlv  affection  with  which  it  is  likelv  to  be 
confounded,  namely,    Hodgkin's    disease   or  pseudoleukemia  (vide' infra) 
Othen^-lse  the  two  have  many  points  of  resemblance. 

_  No  surgical  treatment  is  indicated  in  cases  "of  glandular  enlargement  occur- 
nng  m  the  course  of  leukemia.  In  the  present  state  of  our  knowledge  the 
extirpation  of  these  glands  is  as  irrational  as  extirpation  of  the  spleen  once 
aclvocated  m  this  disease.  Besides  the  difficulties  of  arrest  of  hemorrhage, 
uhich  IS  speciaffy  noticeable  in  leukemia,  a  positive  contraindication  is  to  be 
found  m  the  fact  that  the  disease  on  which  the  local  conditions  depends 
can  be  neither  cured  nor  arrested  bv  this  means. 

Progressive  Multiple  Hypertrophy  of  Lymphatic  Glands  (Hodgkin's 
uisease) ;  Pseudoleukemia.— This  disease,  sometimes  called  malignant 
lymphoma    (B  1 1 1  r  o  t  h),  occurs   in   adolescence   and   middle   life,    and   is 


114  INJURIES    AND    DISEASES    OF    SEPARATE    TISSUES 

characterized  by  an  enlargement  of  the  lymphatic  glands,  first  in  the  neck, 
and  siibseciuently  in  the  axilla  and  inguinal  region.  Other  systems  of  lymph- 
atics become  affected,  and  the  disease  may  finally  involve  the  lymphoid 
tissues  generally  throughout  the  body.  It  is  observed  more  frecjuently  in  the 
female  than  in  the  male.  Single  glands  frequently  enlarggx  to  the  size  of  an 
orange  or  the  fist,  constituting  in  the  neck  a  characteristic  deformity.  Other 
and  neighboring  glands  are  afterward  affected,  these  latter  becoming  attached 
to  those  first  involved,  as  well  as  to  the  underlying  skin,  by  a  low  grade  of 
inflammatory  action.  The  masses  thus  formed  give  rise  to  more  or  less  circu- 
latory disturbances  in  the  intracranial  organs  by  pressure  on  the  veins,  as 
well  as  to  dyspnea  and  dysphagia  by  pressure  on  the  trachea  and  esophagus. 
The  spleen  has  been  known  to  be  enlarged,  and  the  tonsils  and  lymphatic  appa- 
ratus of  the  intestine  as  well. 

Both  the  etiology  and  the  essential  pathology  of  this  disease  are  very 
obscure.  There  can  be  no  doubt  that  it  is  an  infectious  disease,  but  the 
special  microorganism  which  produces  it  still  remains  undiscovered. 

The  principal  difficulty  in  the  diagnosis  of  Hodgkin's  disease  is  the  lia- 
bility to  mistake  it  for  tuberculous  lymphadenitis,  which  it  may  resemble  very 
closely  in  the  beginning  of  the  attack,  for  leukemic  hyperplasia  of  the  lymphatic 
glands,  and  for  sarcoma  of  the  lymphatic  glands.  The  rapid  extension  of  the 
disease  to  other  and  distant  groups  of  glands,  with  absence  of  suppuration  and 
caseation,  will  assist  in  differentiating  it  from  tuberculous  lymphadenitis.  In 
making  this  diagnosis  aid  may  be  obtained,  where  practicable,  by  the  micro- 
scope, tuberculosis  behig  excluded  in  the  absence  of  the  characteristic  bacillus. 
Lymphosarcoma  may  be  excluded  by  the  fact  that  in  this  latter  affection  there  is 
an  early  tendency  on  the  part  of  the  disease  to  proliferate  beyond  the  boundaries 
of  the  gland  structure  and  invade  the  surrounding  tissues.  Large  tumors  thus 
developed  cannot  be  traced  by  palpation  to  the  lymphatic  glandular  tissue, 
while,  on  the  contrary,  in  Hodgkin's  disease  the  mass  can  almost  invariably 
be  so  identified.  Finally,  in  lymphosarcoma  there  is  sooner  or  later  an  involve- 
ment of  the  skin  in  an  ulcerative  process. 

The  prognosis  is  very  unfavorable ;  in  its  later  stages  it  produces  almost 
invariably  a  fatal  result  by  the  supervention  of  extreme  anemia.  The  only 
treatment  which,  up  to  the  present  time,  has  seemed  to  have  any  influence 
on  the  disease  is  the  administration  of  arsenic.  In  the  few  cases  reported 
in  which  success  has  resulted  from  the  use  of  arsenic  the  treatment  was  gener- 
ally commenced  early  in  the  disease,  and  was  continued  over  a  long  period  of 
time.  From  5  to  10  drops  of  Fowler's  solution  (liq.  potass,  arsenitis,  U.S. P.) 
or  corresponding  closes  of  arsenious  acid  may  be  emplo^'ed  daily.  Operative 
interference  here,  as  in  leukemic  hyperplasia  of  lymphatic  glands,  is  not  to 
be  recommended.  The  Rontgen  ray  treatment  is  said  to  have  favorably 
influenced  some  cases. 

INJURIES  AND  DISEASES  OF  THE  NERVES 

Contusions  of  Nerves. — In  a  severe  case  of  contusion  of  a  nerve  the 
pathologic  changes  are  quite  similar  to  those  which  follow  section.  In  cases 
of  less  severity  there  are  points  of  difference  which  relate  chiefly  to  existing  con- 
ditions of  the  nerve  itself.    Thickening  of  the  neurilemma  at  the  point  of  injury, 


INJURIES   AND    DISKASKS   OF   THE   NERVES  115 

(•:iiis(h1  by  a  colloction  of  rouiid-cclls  and  spindlc-colls,  occurs  after  contusion 
(E  r  b),  which  interferes  with  the  process  of  re,2;eneration,  and,  in  the  course  of 
a  few  days,  the  Wallerian  degeneration  sets  in  and  the  medullary  substance 
degenerates;  the  axis-cylinder  is  also  apparently  implicated  in  the  degenerative 
process  (Tillaux).  It  is  asserted  that  the  axis-cylinder  remains  intact 
in  both  the  central  and  the  peripheral  ends  in  slight  injuries,  in  which 
paralysis  is  complete,  though  temporary  (E  r  b),  as  in  the  so-called  "  Saturday- 
night  paralysis."  This  is  observed  in  persons  who  in  the  course  of  a  debauch 
fall  asleep  in  a  chair  with  the  arm  resting  across  the  back  of  the  latter  in  such 
a  manner  as  to  cause  long-continued  pressure  on  the  nerves  in  the  axilla. 
The  lesion  probably  invoh-es  slight  hemorrhage  in  the  sheath.  But  few  fibers 
are  separated,  and  a  large  proportion  of  the  disturbances  are  mechanical, 
involving  simply  a  displacement  of  the  semifluid  contents  of  the  tubules  (Weir 
Mitchell).     Here  degeneration  does  not  occur. 

Contusions  of  nerves  may  be  slight  or  severe,  and  the  symptoms  arising 
therefrom  will  therefore  vary.  In  fact,  a  contusion  of  the  soft  parts  can 
scarcely  occur  without  some  nerve  contusion  resulting,  but  this  relates  to  the 
branches  of  distribution,  and  not  to  nerve-trunks,  which  alone  are  included 
in  the  present  consideration. 

In  the  milder  cases  no  more  serious  symptoms  ensue  than  some  pain  at  the 
injured  point,  and  tingling  and  benumbed  sensations  referred  to  the  periphery, 
combined  with  real  or  imagined  subjective  sensations  of  heat.  These  symptoms 
pass  away  rapidly,  as  a  rule;  as,  for  instance,  in  the  well-known  accident  in 
which  the  ulnar  nerve  is  pressed  against  the  inner  condyle  of  the  humerus  by  a 
blow  on  this  part  of  the  arm.  They  may  remain,  however,  particularly  the 
tingling,  for  several  days.  The  symptoms  may  persist  and  chronic  neuritis, 
with  neuralgic  and  shooting  pains,  supervene;  trophic  changes  are  finally 
established.  In  more  severe  injuries  complete  paralysis  and  anesthesia  of  the 
parts  supplied  by  the  damaged  nerve  ensue.  This  condition  may  pass  away 
rapidly,  may  remain  for  variable  periods  of  time  and  still  be  followed  by  slow 
but  decided  improvement,  or  it  may  become  permanent.  Recovery,  however, 
is  the  rule. 

Severe  crushing  of  long  portions  of  nerve-trunk,  such  as  is  sometimes  seen 
in  machinery  and  railroad  accidents,  explosions,  etc.,  causes  considerable  and 
sometimes  severe  shock.  This  is  characterized  by  a  weak  and  small  pulse, 
pallor  of  the  surface,  and  cold  skin  and  extremities.  Slight  disturbances  of  the 
sensorium  are  present;  rarely  complete  loss  of  consciousness  ensues.  It  is 
extremely  difficult,  however,  under  these  circumstances,  to  determine  how 
much  of  the  shock  is  due  to  the  nerve  lesion  and  how  much  to  the  loss  of  blood 
which  almost  invariably  accompanies  these  injuries. 

.  The  treatment  of  contusions  of  nerves  consists  in  placing  the  parts  at 
perfect  rest ;  if  there  is  much  pain,  this  should  be  relieved  by  an  anodyne.  Later 
on  the  paralyzed  muscles  and  anesthetic  skin  should  be  galvanized  or  fara- 
dized,  and  massage  or  \dgorous  friction  applied.  In  case  chronic  neuritis 
supervenes  the  nerve  may  be  exposed  at  the  seat  of  injury,  and  if  adhesions 
are  found  to  be  present  these  should  be  broken  up  by  nerve-stretching 
(Bowl  by). 

Other  nerve  injuries  arise  from  pressure,  such  as  crutch  paralysis.  This 
is  liable  to  occur  in  those  who  are  unused  to  these  artificial  aids  to  progression; 


116  INJURIES    AND    DISEASES    OF    SEPARATE    TISSUES 

it  is  rare  to  meet  with  examples  of  it  among  those  who  have  been  in  the  habit 
of  using  crutches.  The  symptoms  are  numbness  and  tingling  in  one  or  more 
fingers,  followed  by  weakness  and  loss  of  power  in  the  arm  and  forearm.  Com- 
plete paralysis  may  follow  persistent  efforts  to  use  crutches.  The  duration  of 
the  symptoms  will  depend  on  the  extent  of  the  mechanic  disturbance  of 
the  nerve-trunk  and  the  parts  involved.  The  sensory  symptoms  occur  first 
and  are  the  first  to  disappear.  The  paralysis  affects  some  muscles  more  than 
others,  and  hence  some  recover  more  rapidly  than  others.  The  final  outcome 
of  the  condition  is,  as  a  rule,  recovery. 

Pressure  on  the  nerves  during  sleep  gives  rise  to  symptoms  almost 
precisely  like  the  foregoing.  Here  the  prognosis  does  not  seem  to  be  so  favor- 
able, for,  while  the  sensory  symptoms  pass  away  early,  the  motor  paralysis 
disappears  more  slowly,  and  may  become  permanent.  The  pressure  from  the 
too  prolonged  apphcation  of  an  Esmarch'  s  elastic  tourniquet  during  oper- 
ations on  the  extremities  may  cause  paralysis:  so,  too,  holding  the  arm  in  a 
forcible  manner,  or  allowing  it  to  rest  against  the  hard  and  sharp  corner  or 
edge  of  an  operating  table  during  profound  anesthesia,  may  give  rise  to 
similar  loss  of  function.  Compression  by  tumors,  cicatrices,  etc.,  as  well  as 
pressure  in  bony  canals  through  which  certain  nerves  pass,  occasionally  gives 
rise  to  similar  paralyses. 

The  treatment  of  pressure  symptoms  resolves  itself,  to  a  great  extent,  into  a 
removal  of  the  cause.  Where  other  treatment  is  necessary,  galvanism,  friction, 
etc.,  are  useful.  If,  in  spite  of  treatment,  the  symptoms  persist,  showing  the 
presence  of  adhesions,  and  perhaps  some  thickening  of  the  trunk  itself  from 
chronic  neuritis,  free  exposure  of  the  nerve  is  indicated,  which  is  to  be  freed 
from  surrounding  adhesions  and  stretched. 

Division  of  Nerves. — The  first  change  noticed  after  division  of  a  nerve  is  a 
retraction  of  the  sheath  and  a  spreading  out  of  the  myelin  over  the  cut  ends, 
which  in  a  few  days  become  united  by  a  gray  translucent  tissue.  The  further 
changes  depend  on  the  distance  to  which  the  cut  ends  finally  retract.  The 
nerves  possess  some  elastic  fibers  in  the  neurilemma,  and  the  distance  between 
the  cut  ends  increases  for  several  days  at  least.  If  a  space  of  a  fourth  of  an 
inch  or  more  intervenes,  or  if  this  amount  of  nerve  tissue  is  removed,  regenera- 
tion is  prevented  unless  the  ends  are  brought  together  by  artificial  means. 
The  encls  being  left  separated  for  the  distance  mentioned,  the  space  is  filled 
by  cellular  granulation  tissue  containing  vessels,  which  in  turn  becomes  a 
fibrous  cord  devoid  of  nerve  tissue.  The  ends  of  the  nerves  undergo  degenera- 
tive changes  in  the  meantime  (G  1  u  c  k).  These  changes,  however,  differ  in 
the  two  ends.  In  the  case  of  the  peripheral  end  the  degeneration  commences 
within  a  day  or  two  of  the  injury,  and  continues  until,  within  two  or  three 
weeks,  the  nerve  has  undergone  complete  atrophy.  The  degenerative  changes 
are  marked  by  destruction  of  the  myelin,  multiplication  of  the  nuclei  and  their 
encroachment  on  the  medulla,  and  loss  of  continuity  of  the  axis-cylinder. 
In  the  central  end  the  principal  difference  relates  to  the  axis-cylinder,  which 
remains  intact.  The  nuclei  likewise  multiply  and  increase  in  size,  but,  in- 
stead of  encroaching  on  the  medulla,  they  remain  flattened  against  the 
sheath  of  Schwann.  An  infiltration  of  white  blood-cells  into  the  nerve 
substance  occurs.  The  upper  end  of  the  nerve  becomes  bulbous.  This  has 
been  particularly  noticed  in  stumps  after  amputation.     These  bulbs  were 


INJURIES   AND    DISEASES    OF   THE   NERVES  117 

forniorly  belic^vod  to  be  eoniposcMl  of  simple  fibrous  tissue,  but  it  is  now 
known  tfuit  they  contain  new  nerve-elements  as  well,  or  fully  developed 
nerve-fibers  which  replace  the  altered  distal  portion  of  the  cut  nerve 
(H  a  y  em). 

'J'lie  pain  caused  by  a  division  of  a  nerve-trunk  is  inconsiderable ;  the  patient 
will  usually  refer  to  the  skin  wound  whatever  pain  is  felt.  Numbness  and 
tingling-  cause  more  anxiety  than  the  actual  pain.  In  civil  practice  shock  is 
not  a  prominent  symptom  of  nerve  division,  although  in  military  practice,  in 
which  the  nerve  is  divided  by  a  missile  or  projectile,  the  shock  may  be  con- 
siderable. Loss  of  muscular  power  and  of  the  sense  of  touch  immediately 
supervene,  and  continue  as  long  as  the  nerve  remains  divided.  Sensation 
maj^  be  affected  in  many  ways;  there  may  be  loss  of  sense  of  touch  and  of 
temperature;  analgesia,  hyperesthesia  and  anesthesia,  and  various  other 
abnormal  sensations,  such  as  prickling,  tingling,  numbness  (paresthesia),  etc., 
may  be  present. 

The  thermal  sense  is  generally  lost  in  proportion  to  the  loss  of  the  sense 
of  touch,  and  extends  over  about  the  same  areas  as  the  latter.  It  may  be 
altogether  absent.  Patients  exhibit  no  appreciation  of  heat  and  cold  as 
applied  to  the  surface  in  some  instances  in  which  complete  anesthesia  is  not 
present. 

The  anesthesia  following  a  nerve  injury  varies  in  extent,  and  is  quite 
difficult  to  estimate.  The  distance  at  which  the  two  points  of  a  pair  of  com- 
passes can  be  distinguished  on  the  affected  surface,  as  compared  with  the 
distance  at  which  they  can  be  distinguished  on  a  corresponding  portion  of 
the  body  on  the  opposite  side,  is  the  best  means  of  testing  the  tactile  sense. 
The  sense  of  locality  may  also  be  diminished  or  lost.  Error  may  be  avoided 
by  light  touches  of  the  compass  points  arising  from  vibrations  conveyed  to 
surrounding  and  sensitive  parts.  The  application  of  friction  tests  should  be 
carefully  applied  for  the  same  reason.  In  making  the  examination  the 
condition  of  the  skin  should  be  taken  into  account.  The  hand  of  a 
working-man,  for  instance,  in  conditions  of  health  is  sometimes  so  insensitive 
as  not  to  recognize  contact  of  any  kind. 

Complete  and  permanent  anesthesia  need  not  necessarily  occur  in  the  area 
of  distrilDution  of  a  sensory  nerve,  even  in  complete  section  of  the  nerve-trunk. 
In  given  cases  it  is  difficult  to  determine  in  case  of  returning  sensibility  whether 
the  improvement  is  due  to  nerve  anastomosis  or  to  true  nerve  regener- 
ation, and  only  an  examination  of  the  ends  of  the  divided  nerve  can 
decide  the  question.  It  is  probable  that  neighboring  nerve  branches,  passing 
within  the  area  of  distribution  of  the  affected  nerve,  convey  sensation  from  that 
area.  In  recent  cases  and  in  indubitable  retraction  of  the  divided  nerve 
ends  the  occurrence  of  sensation  in  the  affected  area  can  be  attributed  only  to 
nerve  anastomosis.  The  importance  of  differentiating  these  two  causes  of 
returning  sensibility  is  apparent  when  the  question  of  operative  interference 
and  its  results  is  to  be  discussed.  The  reaction  which  the  muscles  affected 
show  to  the  different  electric  currents  will  likewise  govern  the  prognosis. 
The  persistence  of  the  reaction  of  degeneration  for  a  period  longer  than  six 
months,  during  which  time  the  degenerative  process  is  going  on,  and  at  the  end 
of  Avhich  regenerative  processes  may  be  expected  (W  a  1 1  e  r),  will  be  usually 
followed  by  further  changes  of  a  decidedly  hopeless  character. 


118  INJURIES    AND    DISEASES    OF    SEPARATE    TISSUES 

Trophic  changes  are  chiefly  of  a  degenerative  nature,  though  they  may 
be  combined  with  inflammatory  conditions.  All  of  the  changes  grouped  under 
this  head  are  not  present,  and  some  of  them  are  of  very  infrequent  occurrence. 
The  trophic  changes  include  the  glossy  and  atrophied  skin,  almost  devoid  of 
wrinkles,  and  tapering  fingers  with  curved  nails,  which  may  be  quite  soft  or 
abnormally  brittle.  Eczematous  as  well  as  herpetic  eruptions  may  occur. 
Ulceration  and  abscess  and  even  gangrene  may  likewise  be  present.  In 
parts  where  hair  grows,  changes  in  the  latter  are  very  common.  There  is 
either  an  atrophy  of  the  hair-follicles  and  loss  of  hair,  or  the  hair  becomes  very 
short  and  brittle.  The  sudoriferous  glands  also  atrophy,  and  a  dry  condition 
of  the  parts  results.  Changes  of  temperature  are  observed,  that  of  the 
affected  parts  becoming  elevated,  as  a  rule.  Rapid  atrophy  and  degeneration 
of  the  muscles  occur.  The  muscles  are  transformed  into  fibrous  tissue,  and 
deprived  of  contractility  and  elasticity;  fatty  degeneration  may  be  added  to 
this.  These  changes  come  on  gradually,  the  muscle  wasting  in  bulk.  Trophic 
changes  of  the  bones  are  of  comparatively  rare  occurrence.  The  changes 
are  chiefly  of  an  atrophic  character.  Shortening  of  the  long  bones  has 
been  observed.  The  arthritic  changes  may  occur  shortly  after  the  injur}', 
or  at  a  later  period.  One  or  more  joints  may  be  involved.  In  case  but  one  is 
attacked,  it  is  likely  to  be  a  large  one.  The  joints  become  stiff,  swollen,  and 
exquisitely  tender  on  touch  and  motion  (Mitchell).  Some  cases  are  less 
severe  and  of  a  more  chronic  type.  The  exact  pathology  of  these  joint  lesions 
has  not  as  yet  been  determined.  The  possibility  of  obtaining  restoration  of 
function  immediately  on  the  completion  of  primary  union  is  often  disputed, 
but  it  occurs,  though  very  rarely.  If  not  more  than  a  quarter  of  an  inch 
intervenes  between  the  nerve  ends,  and  provided  a  large  amount  of  cicatricial 
tissue  does  not  intervene,  restoration  may  take  place,  after  intervals  varying 
from  nine  months  to  a  year  and  a  half.  Restoration  has  taken  place  after 
twenty-one  months  (B  o  w  1  b  y). 

Treatment. — The  most  rational  method  of  treatment  consists  in  the 
immediate  or  primary  suture  of  the  nerve  ends.  The  attempt  should  always 
be  made  to  secure  primary  union.  Even  if  this  fails,  the  nerve  is  left  in  a  much 
better  condition  for  subsecjuent  regeneration,  by  the  prevention  of  excessive 
retraction,  than  would  be  the  case  otherwise.  (For  the  technic  of  nerve 
suture,  see  page  354.) 

The  operation  of  secondary  suture  is  performed  some  time  after  the  inflic- 
tion of  the  original  injury,  and  is  most  commonly  resorted  to  in  cases  in 
which  no  attempt  has  been  made  to  secure  primary  union  of  the  divided  nerve. 
It  may  be  attempted  before  the  wound  has  entirely  healed,  or  delayed  after 
cicatrization  is  completed.  The  sole  indications  for  its  performance  are  the 
existence  of  symptoms  which  show  that  a  nerve  has  been  divided  and  has 
not  united. 

Inflammation  of  Nerves. — Nerves  are  not  particularly  prone  to  inflam- 
mation, in  spite  of  their  delicate  structure.  The  pain  present  in  acute  inflam- 
matory conditions  is  partly  the  result  of  an  involvement  of  the  nerves,  and 
partly  due  to  the  pressure  exercised  by  the  products  of  inflammation.  Large 
nerve-trunks  are  peculiarly  insusceptible  to  acute  inflammation  in  their  neigh- 
borhood. Phlegmonous  suppuration  not  rarely  follows  the  connective  tissue 
along  a  large  nerve-sheath,  without  apparent  disturbance  of  the  nerve  itself. 


INJURIES    AND    DIRKASES    OF   THE    NERVES     ■  119 

Suppuration  of  nerves  is  extremely  rare,  the  immunity  being  most  probably 
due  to  the  fact  that  the  laminated  sheath  presents  an  almost  insurmountable 
barrier  to  the  diffusion  of  pus  into  the  interior  of  the  fasciculi  (C  o  r  n  i  I  and 
K  a  n  V  i  e  r).  A  suppurative  inflammation  involving  destruction  of  a  nerve- 
trunk  with  paralysis  in  the  area  of  its  distribution  is  luiknown. 

In  inflammation  of  nerves  the  result  of  traumatism  (traumatic  neuritis) 
the  new  cell-formation  is  continued  into  the  perifascicular  connecti\'e  tissue, 
and  between  the  la^^ers  of  the  laminated  sheath  of  the  nerve  fasciculi.  The 
laminae  become  separated,  the  fasciculi  are  compressed,  and  the  nerve-fibers 
below  the  diseased  spot  undergo  degenerative  changes.  The  more  chronic 
the  inflammatory  process,  the  greater  is  the  tendency  to  the  development  of 
inflammatory  products.  In  chronic  neuritis,  therefore,  a  general  enlargement 
of  the  nerve  due  to  the  growth  of  tissue  of  new  formation  between  the  fasciculi 
is  found.  The  compression  exercised  by  the  latter  interferes  with  the  nutri- 
tion of  the  nerve,  and  degeneration  takes  place  precisely  similar  to  the  changes 
observed  in  the  peripheral  end  after  division. 

Neuritis  is  subdivided  into  the  localized  and  spreading  forms.  The 
latter  form  is  the  more  serious. 

Neuritis  following  an  injury  to  a  nerve  is  by  no  means  a  common  affection. 
It  results  more  frequently  from  contused  and  lacerated  wounds  than  from  clean 
incised  ones.     Septic  conditions  of  w^ounds  favor  its  occurrence. 

Symptoms. — Pain  at  the  seat  of  injury,  spreading  along  the  sheath  of  the 
damaged  nerve,  and  sometimes  felt  in  the  neighboring  trunks,  and  fibrillar 
tremors  or  spasmodic  movements  of  the  muscles  are  the  most  common  symp- 
toms. Paresis  or  paralysis  and  trophic  changes  in  the  area  of  distribution 
may  occur.  Sensitiveness  to  pressure  and  a  hardened  feeling  along  the  nerve- 
trunk  are  sometimes  observed.  Extension  of  the  symptoms  occurs  over  a 
larger  area  as  fresh  nerve-trunks  or  branches  are  implicated  (spreading  neu- 
ritis). In  this  form  the  pain  is  more  severe  at  the  commencement,  but  sub- 
sides later  on,  owing  either  to  a  subsidence  of  the  inflammation  or  to  destnic- 
tion  of  the  nerve-fibers. 

The  prognosis  of  acute  neuritis  will  depend  on  the  extent  of  the  damage 
inflicted,  as  shown  by  the  severity  of  the  symptoms.  The  length  of  the  attack, 
as  well  as  the  final  result,  will  vary.  Recovery  may  follow  or  chronic  neuritis 
may  ensue. 

Chronic  neuritis  is  marked  by  pain  and  tenderness  along  the  affected 
nerve,  followed  b}'^  exacerbations  of  numbness  and  tingling  pains  in  the  per- 
ipheral distribution,  dull  aching  pains  increased  at  night,  and  sometimes 
hyperesthesia  of  limited  areas  of  skin.  Trophic  changes  occur.  Some  enlarge- 
ment and  hardening  along  the  affected  nerve  may  be  perceptible.  The  mus- 
cles to  which  the  latter  is  distributed  are  at  first  the  seat  of  twitchings;  later 
paralysis  with  wasting  occurs.  Their  electric  reactions  decrease  at  the 
same  time.  The  disease  may  remain  localized  or  spread,  the  tenderness 
in  the  originally  affected  nerve  subsiding  with  the  occurrence  of  destructive 
changes,  while  the  nerves  secondarih'  in^'olved  become  in  time  inflamed,  tender, 
and  enlarged. 

Extension  of  the  inflammation  to  the  spinal  cord  (ascending  neuritis) 
has  been  obser\-ed  clinically  as  one  of  the  sequences  of  neuritis,  the  symptoms 
pointing  to  inflammation  and  sclerosis  of  the  cord. 


120  INJURIES   AND   DISEASES   OF   SEPARATE   TISSUES 

Treatment. — In  the  acute  form  complete  rest,  with  apphcation  of  cold 
(ice-bags)  or  evaporating  lotions,  and  opium  for  the  relief  of  pain,  are  indi- 
cated. Leeches  and  cupping  are  also  recommended.  In  the  chronic  form 
mercury  or  the  iodid  of  potassium  is  to  be  administered  internally,  and  ano- 
dynes employed.  Counter-irritation  is  useful  (thermocautery).  Clalvanism 
and  faradism  ma}'  also  be  employed  with  benefit.  Nerve-stretching  may  be 
of  service.  In  aggravated  cases,  with  great  suffering  and  a  practically  use- 
less limb,  amputation  may  be  resorted  to.  Even  this  may  not  avail,  the  pains 
persisting  in  the  stump. 

INJURIES  AND  DISEASES  OF  FASCIAE,  MUSCLES,  AND  TENDONS 

Injury  and  Inflammation  of  Fasciae. — The  fasciae  are  distinguished 
by  very  wide  variations  in  both  extent  and  composition.  Many  of  them  are 
simple  planes  of  connective  tissue  spread  out  beneath  the  integument  or 
between  muscular  layers,  such  as  the  fascia  of  the  neck,  perineum,  etc.  These 
do  not  need  special  study  here,  inasmuch  as  the  diseased  conditions  of  the 
fasciae  in  these  regions  are  almost  identical  with  those  of  the  subcutaneous  cel- 
lular tissue  already  described  (see  page  66).  The  rigid  fasciae,  composed  of 
solid  transverse  fibers,  such  as  the  fascia  found  in  the  anterobrachial  region, 
the  fascia  lata  of  the  thigh,  and  the  palmar  and  plantar  fasciae;  present 
certain  peculiar  characteristics  worthy  of  notice. 

Incised  wounds  of  the  fascia,  if  made  in  a  direction  parallel  to  the  direction 
of  the  fibers,  gape  but  slightly;  on  the  contrary,  if  made  in  a  direction  to  cross 
the  fibers,  they  gape  considerably.  These  points  are  to  be  borne  in  mind  when 
making  incisions  for  the  purpose  of  evacuating  pus  or  reaching  an  inflamma- 
tory focus  in  the  palm  of  the  hand  or  the  sole  of  the  foot.  In  the  latter  situa- 
tion, the  fibers  run  in  a  longitudinal  direction,  and  incisions  in  this  direction 
gape  but  slightly.  In  the  palm  of  the  hand  the  fibers  are  placed  trans^'ersely 
to  the  long  axis  of  the  part. 

Inflammation  of  Fasciae. — Fasciae  and  aponeuroses  contain  compara- 
tively few  vessels,  and  are,  therefore,  but  passive  agents  in  inflammatory 
processes.  They  serve  as  barriers  in  limiting  suppurative  processes.  In 
extensive  phlegmonous  inflammation,  and  in  the  burrowing  of  pus,  this 
does  not  suffice,  for  the  reason  that  weak  points  exist  here  and  there, 
particularly  at  localities  where  blood  and  lymphatic  vessels  pass  through.  At 
these  points  pus  and  other  septic  products  pass  from  one  side  of  the  fascia 
to  the  other.  It  is  a  noticeable  fact,  however,  that  while  a  subfascial  suppura- 
tion is  quite  likely  finally  to  find  its  way  toward  the  surface,  a  subcutaneous 
phlegmonous  inflammation,  on  the  contrary,  is  usually  limited,  as  to  depth, 
by  the  fascia.  This  is  due  in  part  to  the  strong  pressure  exercised  by  the  tense 
fascia  in  case  there  are  accumulations  of  pus  beneath.  This  circumstance 
likewise  favors  the  absorption  of  septic  material  from  subfascial  suppuration, 
and  increases  septic  fever. 

Inflammatory  necrosis  of  fasciae  is  quite  commonly  observed,  particu- 
larly where  a  phlegmonous  suppuration  invades  both  sides  of  the  fascia.  This 
tendency  to  sloughy  conditions  is  also  explained  by  the  presence  in  its  struc- 
ture of  a  relatively  small  number  of  blood-vessels.  In  case  of  extensive  injury 
and  loss  of  substance,  laying  bare  areas  of  fascia,  granulations  spring  up  very 


INJURIES  AND  DISEASES  OF  FASCIAE,    MUSCLES,    AND   TENDONS  121 

slowly  on  the  latter;  vascularization  of  the  fascia  must  occur  before  the 
latter  is  able  to  })ro(luce  granulations. 

Injuries  of  Muscles. — In  injuries  of  muscles  the  contractility  of  the 
latter  play  an  important  role.  When  the  fibers  are  separated  in  a  trans- 
verse direction,  the  wound  gapes  in  proportion  to  the  extent  of  the  division. 
The  application  of  force  by  a  blunt  instrument  may  result  in  a  separation 
of  the  muscular  fibers  by  driving  them  against  the  bone  underneath,  the  skin 
and  fascia  escaping.  Rupture  of  a  muscle  may  likewise  occur  without  the 
application  of  external  force  (see  Injuries  of  Special  Parts).  The  torn  blood- 
vessels pour  out  a  mass  of  blood,  which  fills  up  the  gap  between  the  injured 
muscular  fibers.  The  connective  tissue  proliferates  rapidly  in  the  coagula  and 
the  latter  are  alosorbed,  leaving  a  swelling  of  exce]3tionally  firm  consistency, 
the  so-called  muscle  callus,  or  muscular  cicatrix.  In  this,  muscular  fibers 
may  finally  develop. 

Inflammation  of  Muscles. — With  the  exception  of  some  forms  of  so-called 
rheumatic  affections  of  muscles  (lumbago,  etc.),  inflammation  of  muscles  is  of 
rare  occurrence.  In  certain  conditions  of  deficient  or  erratic  metabolism 
characterized  by  uricemia,  infiltrations  occur  in  the  muscular  and  subcu- 
taneous connective  tissue.  There  may  be  considerable  interference  with  the 
function  of  parts  controlled  by  the  muscles  involved,  and  pain  and  inability  to 
relax  these  on  motion.  The  involvement  of  nerves  in  the  infiltration  will 
lead  to  painful,  paresthetic,  and  anesthetic  areas. 

A  peculiar  variety  of  hyperplastic  inflammation,  characterized  by  the  flnal 
development  of  genuine  bony  plates,  affects  muscular  structures,  and  is  known 
as  myositis  ossificans.  The  affection  may  be  traumatic  or  nontraumatic. 
Heredity  is  supposed  to  influence  its  production.  Osteomas  and  osteophytes 
sometimes  occur  simultaneously.  The  x-ray  may  be  employed  to  assist  the 
diagnosis.  Treatment  in  the  nontraumatic  variety  is  generally  useless.  In 
traumatic  cases  complete  excision  may  give  relief  (Keen). 

Phlegmonous  inflammation  f  oho  wing  the  plane  of  connective  tissue  be- 
tween the  muscles  (the  paramuscular  connective  tissue)  constitutes  what  is 
sometimes  known  as  suppurative  myositis.  This  affection  originates,  as  a 
rule,  in  the  bony  or  periosteal  structures.  While  the  sheath  of  the  muscle  may 
be  invaded  by  phlegmonous  inflammation,  and  in  rare  instances  the  intra- 
muscular connective  tissue  hkewise,  the  inflammation  spreading  between  single 
bundles  of  fibers,  it  is  very  exceptional  for  the  muscular  fibriUae  and  sarco- 
lemma  sheaths  to  become  involved.  It  is  not  an  uncommon  thing  to  observe 
muscular  structures  intact  in  the  midst  of  a  perfect  wreck  of  tissue,  bathed 
in  pus  and  surrounded  by  structures  involved  in  suppurative  destruction. 
Small  abscesses  may  be  found  exceptionally  on  the  belly  of  the  muscles. 
In  metastatic  or  pyemic  infection  abscesses  occur  near  the  insertion  of 
certain  muscles  (flexor  carpi  ulnaris,  quadriceps  extensor  femoris). 

In  glanders,  particularly  in  the  slowly  developing  forms,  multiple  abscesses 
appear  in  the  muscular  structures.  In  syphilis  a  gumma  of  the  muscular  struc- 
ture may  suppurate,  producing  abscess. 

The  migration  of  trichinae  into  muscular  tissue  produces  edematous  swell- 
ings, but  these  are  circulatory  disturbances  rather  than  the  resiflt  of  inflamma- 
tory irritation. 

Sarcomas  of  voluntary  muscles  are  somewhat  rare.     The  majority  of 


122  INJURIES    AND    DISEASES    OF    SEPARATE    TISSUES 

the  cases  have  occurred  in  the  muscles  of  the  lower  extremities.  They  may 
occur  at  any  period  of  life  from  young  adult  age  to  sixty.  A  locahzed 
involvement  of  the  sheath  is  first  observed,  the  disease  afterward  extending  to 
the  belly  of  the  muscle.  The  localized  induration  of  a  sarcoma  of  a  voluntary 
muscle  may  be  mistaken  for  a  syphilitic  gumma  in  a  patient  with  a  syphilitic 
history.  Invasion  of  muscle  from  adjacent  sarcomas,  particularly  of  the  peri- 
osteal variety,  is  common.  It  may  also  occur  in  sarcoma  of  the  uveal  tract 
following  the  involvement  of  the  sclerotic,  the  disease  finally  infiltrating  the 
muscles  of  the  globe. 

Sarcomas  of  involuntary  muscle-fiber  are  exceedingly  rare.  Those  which 
affect  the  uterus  have  their  origin  in  the  endometrium. 

Injuries  and  Diseases  of  Tendons. — Subcutaneous  contusions  of  tendons 
are  of  rare  occurrence,  owing  to  the  solid  consistency  of  these  structures.  Aside 
from  incised  wounds,  the  most  common  injury  to  which  tendons  are  subject 
is  rupture  or  the  tearing  off  of  the  tendon  at  its  point  of  insertion,  by  exces- 
sive contraction.  This  occurs  more  particularly  in  the  great  quadriceps  exten- 
sor femoris  at  its  point  of  attachment  to  the  patella.  In  modem  times  not 
infrequently  machinery  accidents  produce  rupture  of  tendons  in  the  hand  and 
forearm. 

Incised  wounds  of  tendons  are  of  rather  frequent  occurrence.  These  are 
observed  particularly  about  the  anterior  carpal  region,  arising  from  suicidal 
attempts  to  sever  the  vessels  at  the  wrist.  They  are  also  observed  rather 
frequently  in  domestic  servants  as  a  result  of  accidentally  pushing  the  hand 
through  the  windowglass  in  cleaning.  The  posterior  metacarpal  region  suffers 
among  house  carpenters,  the  injury  being  caused  by  edged  tools  falling  from 
a  height.  The  tendo  Achillis  is  sometimes  divided  in  the  same  way,  the 
falling  implement  striking  the  tense  tendon  just  as  the  individual  is  taking  a 
forward  step  with  the  other  foot.  Immediate  and  accurate  suture  should 
always  be  attempted  in  order  to  restore  the  function  of  the  divided  tendon 
(see  page  358). 

In  subcutaneous  tenotomy  for  the  correction  of  deformities,  particularly 
of  talipes,  a  "splice''  of  tendinous  tissue  unites  the  divided  ends  by  means 
of  connective- tissue  proliferation.  This  proliferation  originates  in  the  con- 
nective-tissue covering  of  the  tendon,  a  portion  of  which  stretches  from  one 
extremity  to  the  other  after  the  division  of  the  tendon  proper  (Adams). 
Increased  vascularity  of  the  vessels  in  this  connective  tissue  occurs,  but  the 
extravasation  of  blood  from  the  divided  vessels  of  either  the  skin  or  the 
connective  tissue  between  the  divided  ends  is  not  essential  and  may  be  dis- 
advantageous to  the  reparative  process. 

Tendons  are  not  invaded  by  suppurative  inflammation,  owing  to  the 
comparative  absence  of  blood-vessels  in  children,  and  their  entire  absence  in 
adults.  Pus-corpuscles  may  migrate  into  the  nutritive  channels,  and  blood- 
vessels may  invade  the  tendon  during  the  granulating  process  in  the  course 
of  repair.  This  latter  circumstance  is  rather  unfortunate  than  otherwise,  as 
the  function  of  the  tendon  is  likely  to  be  interfered  with  by  the  adhesions 
which  form  as  the  result  of  this  vascularization.  Still  worse,  however,  is  the 
necrosis  of  tendon  which  occurs  somewhat  freciuently  in  the  course  of  a 
phlegmonous  inflammation  in  the  paratqndinous  structures. 

In  manv  localities  genuine  synovial  cavities  develop  in  the  course  of  the 


INJURIES    AND    DISEASES   OF   BONES  123 

paratendinous  tissues,  f<)i-inin<;-  a  true  synovial  sheath.  The  inflammatory 
processes  miiy  attack  the  synovial  lining  of  the  sheaths,  constitutin«;  the 
so-called  tenosynovitis.  This  synovial  inflammation  is  practically  identical 
with  that  which  occurs  hi  joints,  and  will  be  discussed  in  connection  with  these 
structures  (see  page  151). 

Treatment  of  Inflammation  of  Muscles  and  Tendons. — The  preserva- 
tion of  the  function  of  muscles  is  of  very  great  importance,  and  special  care 
should  be  taken  to  prevent  burrowing  of  septic  material  along  the  surfaces  of 
muscles  and  tendons.  To  this  end,  early  and  free  incision  in  spreading  sep- 
tic conditions,  whether  of  phlegmonous  inflammation  or  of  burrowing  pus,  must 
be  made  and  efficient  drainage  provided  for.  Great  damage  may  be  inflicted 
on  the  function  of  muscles,  even  when  these  are  not  actually  invaded  by 
the  inflammatory  process,  by  considerable  masses  of  granulations  develop- 
ing between  the  bellies  of  the  same,  or  about  the  tendinous  structures. 
Cicatricial  tissue  forms,  and  this  may  prevent  the  contraction  of  the  muscle. 
The  interdependence  of  the  muscular  groups  on  one  another,  as  well  as  the  con- 
joint action  of  muscles  of  the  same  group,  demands  the  utmost  freedom  of 
motion.  Muscles  of  one  group,  if  impaired  in  their  function,  limit  the  useful- 
ness of  opposing  muscles. 

Under  these  circumstances  of  impairment  of  function,  due  to  the  effects  of 
intermuscular  inflammatory  conditions,  much  benefit  may  be  derived  from 
the  employment  of  passive  motion.  This  may  be  accomplished  at  first  under 
an  anesthetic,  but  subsequently  the  latter  maybe  omitted.  Complete  flexion 
and  extension  being  accomphshed,  the  employment  of  massage,  conjoined  with 
systematic  passive  movements,  constitutes  the  most  efhcient  means  at  our 
disposal.  The  so-called  muscular  rheumatism  and  erratic  infiltration  are  like- 
wise very  efficiently  treated  by  massage  and  faradization.  Articles  of  food  con- 
taining notable  quantities  of  the  purin  bodies,  which  are  supposed  to  stand  in  a 
causative  relation  to  the  uricemia,  are  to  be  avoided,  such  as  certain  meats  and 
fish,  particularly  salmon,  the  glandular  structure  of  animals  (sweet-breads,  thy- 
mus, liver,  etc.),  pulse  (peas  and  beans)  and  asparagus,  coffee,  Ceylon  and 
India  tea,  and  ale.  The  usual  antirheumatic  remedies  are  useless,  and  some  of 
the  most  vaunted,  such  as  salicylate  of  soda,  are  positively  contraindicated. 

Motor  paralyses  are  also  benefited  by  massage.  Although  somewhat  pain- 
ful in  the  application,  there  is  no  better  method  of  treatment  than  massage 
for  muscular  hematoma  and  serous  effusions  within  muscles. 


INJURIES  AND  DISEASES  OF  BONES 
Contusion.— Force  directly  applied  to  a  bone  is  felt  (1)  in  its  periosteal 
covering;  (2)  in  its  cortical  substance;  (3)  in  its  medullary  substance. 
Slighter  forms  of  contusion  occur,  particularly  in  bones  superficially  situated, 
such  as  the  tibia,  ulna,  etc.  In  fracture  from  direct  violence,  contusion  and 
fracture  are  combined.  Fissure  of  a  bone,  in  the  direction  of  its  long  axis, 
occupies  a  ground  midway  between  contusion  and  fracture.  It  does  not 
interrupt  the  continuity  of  the  bone.  Occasionally  these  fissures  assume  a 
spiral  direction,  and  have  been  designated  spiral  fractures  (Fig.  22). 
They  have  been  known  to  occur  by  indirect  violence,  the  patients  having  been 
crushed,  from  above,  beneath  heavy  masses  of  earth,  etc. 


124  INJURIES   AND    DISEASES    OF    SEPARATE    TISSUES 

Contusion  of  bone  is  not,  as  a  rule,  an  important  form  of  injury.  Extra- 
vasated  blood  is  soon  resorbed;  a  slight  thickening  may  remain.  Very  rarely 
suppurative  or  phlegmonous  inflammation  follows.  The  infection  producing 
this  finds  its  way  to  the  point  of  injury,  either  from  the  skin  or  through  the 
medium  of  the  effused  blood.  The  latter  view  is  supported  by  the  occurrence 
of  nontraumatic  infectious  osteomyehtis  and  of  syphilitic  affection  of  bones. 
Extravasation  within  the  medullary  cavity  of  bone  still  more  rarely  results 
seriously,  though,  in  certain  cases,  inflammation  and  suppuration  may 
develop.  The  course  of  the  blood  through  the  medullary  tissue  favors  the 
arrest  of  corpuscular  elements  between  the  cells  of  the  latter.  (See  Traumatic 
Inflammation  of  Bone,  page  139.) 

FRACTURES 
Classification  of  Fractures. — Fractures  of  bones  are  divided  into  in- 
complete, complete,  and  comminuted;   simple  and  complicated. 

The  Relations  of  Direct  and  Indirect  Force  to  Fracture. 

— Fracture  may  be  the  result  of  direct  and  indirect  violence. 
In  the  former  the  force  strikes  the  bone  directly,  while  in  the 
latter  it  is  transmitted  through  some  other  portion  of  the 
skeleton.  When  an  entire  extremity  is  exposed  to  the  force, 
it  is  simply  a  question  whether  certain  ligaments  are  to  be- 
come ruptured  and  a  dislocation  produced,  or  one  or  more  of 
the  bones  are  to  give  way.  When  indirect  force  produces  the 
fracture,  one  portion  of  the  extremity  is  fixed  by  muscular 
contraction,  and,  acting  as  the  fixed  arm  of  a  lever,  transfers 
the  force  to  the  bone,  which  gives  way. 

Seat    of   Fracture. — The   point    of   fracture,    other  things 
being  equal,  will  be  at  the  place  of  least  resistance,  and  this, 
in  its  turn,  will  depend  on  the  relation  of  the  cortical  sub- 
stance to  the  medullary  and  cancellated  tissues.     The  middle 
of  long  bones  marks  the  site  of  the  first  or  diaphysial  center 
of    ossification,   and   at   this   point   the   cortical   lamellae    are 
strongest  and   the  cancellated   structure  absent.     In    the   di- 
rection of  the  epiphysis,  where   later   ossification   occurs,  the 
cortical   lameflae    are   much   thinner,    and    cancellated    tissue 
is    abundant.     The    long    bones,    therefore,    are    more    solid, 
though  they  are    brittle    at    the    middle,    and    the    tissue   at 
^'tkactor"^'*'^  the  extremities   is  loosely  built  up.     In  indirect  force,  there- 
fore, it  is  the  upper  or  the  lower  third  of  the  bone  which  yields, 
while  in  direct  force,  received  in  the  middle,  the  latter  gives  way.     In  addition, 
direct  force  may  produce  a  fracture  wherever  it  is  expended. 

The  Character  of  the  Force. — A  classification  of  the  causes  of  fracture, 
owing  to  their  number,  is  almost  impossible.  Projectiles  from  the  modern 
rifle,  as  a  rule,  pass  directly  through  the  bone;  those  from  the  old-time 
smooth-bore  generally  lodged  withm  the  bone.  A  partially  spent  ball  may 
likewise  follow  the  latter  course.  In  the  case  of  the  former  a  "punched  out" 
effect  is  produced.  The  ball  carries  a  portion  of  the  bone  ahead  of  it,  as  a 
solid  punch  would  make  a  hole.  This  occurs  more  particularly  in  the 
diaphysis,  where  the  effect  is  something  like  that  which  follows  the  passage 


INJURIES   AND    DISEASES   OF    BONES 


125 


of  a  l)all  throus'i  :^  wiiulow-pane.     In  the  neighborhood  of  a  joint  the  ciishion- 
Ukc  structure  of  the  c])iph>-sis  may  arrest  the  ball  and  cause  its  lodgment. 

In  civil  life  falls  are  the  most  common  cause  of  fracture.  Here  the  force 
producing  the  fracture  depends  on  the  distance  which  the  body  falls,  the 
weight  of  the  body,  and,  in  case  of  fracture  of  an  extremity  by  indirect  force, 
the^length  of  the  lever  through  which  the  force  is  transmitted.  Crush- 
ing beneath  heavy  objects  (fallhig  banks  of  earth)  and  muscular  contrac- 
tion may  also  be  mentioned.  In  the  case  of  the  latter  the 
bony  insertions  of  muscles  are  usually  torn  off.  Exception- 
ally a  long  bone  may  be  fractured  by  muscular  force,  as,  for 
instance,  in  fracture  of  the  humerus  occurring  in  baseball 
pitchers. 

Direction  of  the  Line  of  Fracture.— The  hne  of  frac- 
ture may  be  longitudinal,  transverse,  or  oblique.  The 
first  named  is  rare.  Ouly  a  direct  and  very  considerable  force 
can  produce  a  fracture  of  a  long  bone.  A  purely  transverse 
fracture  is  also  rare,  for  the  reasori  that  the  line  of  fracture 
will  follow  the  direction  of  least. resistance,  and  this  differs 
according  to  the  arrangement  of  the  lamellae.  The  latter,  on 
transverse  section,  do  not  show  the  same  degree  of  solidity 
at  all  points;  the  line  of  separation  may  show  a  zigzag  line 
for  this  reason  (dentated  fracture).  From  the  bottom  of 
the  dentations  fissures  may  run  in  an  oblique  or  longitudinal 
direction  (Fig.  23),  according  to  the  direction  of  the  lamellae, 
constituting  a  splintered  fracture. 

Comminuted  Fracture.— Where  several  splinters  are 
loosened,  or  more  than  two  fragments  are  found  at  the  site 
of  fracture,  the  latter  is  said  to  be  comminuted.  Brittle- 
ness  of  the  bones,  great  velocity  of  the  effecting  force, 
machinery  accidents,  and  crushing  by  means  of  a  heavy 
broad  surface,  such  as  the  wheel  of  a  railway  car,  are  the 
common  causes  of  comminuted  fracture. 

Incomplete  Fracture.— The  most  common  form  of  in- 
complete fracture  is  the  subperiosteal  fracture.  These 
occur  more  particularly  in  rachitic  children  with  thickened 
periosteum,  the  untorn  periosteum  retaining  the  fragments 
in  position.  Partial  preservation  of  the  periosteum  also  oc- 
curs in  cases  grouped  under  the  head  of  epiphysial  separa- 
tion. This  is  a  true  fracture,  i.  e.,  it  is  not  a  separation  at 
the  cartilage  of  the  epiphysis,  but  of  the  bony  structure  at 
the  very  youngest  layer  of  the  diaphysis.  It  constitutes  the 
most  typic  form  of  transverse  fracture.  It  is  not  so  common  as  was  formerly 
supposed. 

Green-stick  Fracture  (Infraction).— The  inherent  elasticity  of  young 
bone  permits  more  or  less  bending  before  fracture  occurs.  Bones  of  children 
vield  somewhat  in  this  way  before  breaking.  This  increased  elasticity _  is 
compensated  for,  however,  by  the  lessened  diameter  and  diminished  cohesive 
qualities.  In  this  forcible  bending  of  bones  which  are  somewhat  elastic,  single 
lamellae  give  way  and  a  sphntered  effect,  such  as  follows  the  forcible  bending 


Fig.  2.3. — An    Ob- 
lique Fracture 
WITH  Dentated 
Surfaces, Splin- 
tering,AND  Com- 
minution . 
1,    Oblique    line 
of     fracture     with 
dentated    surfaces; 
2,  2,  2,  2,  line  of  fis- 
sures ;   3,  an    isola- 
ted fragment    con- 
stituting a  commi- 
nuted fracture. 


126 


INJURIES   AND    DISEASES    OF   SEPARATE   TISSUES 


of  a  o-reen  twig,  occurs  (Fig.  24).  Green-stick  fracture  differs  from  impacted 
fracture  in  that,  while  in  the  former  some  of  the  lamellae  give  way  and  others 
maintain  their  integrit^y,  in  the  latter  the  entire  thickness  of  the  bone  is  trav- 
ersed by  the  line  of  fracture.  In  this  sense,  therefore,  the  fracture  is  com- 
plete, though  at  first  glance  there  is  no  displacement  apparent.  This,  how- 
ever, is  delusive,  as  shortening  of  the  limb  occurs,  and  there  is  therefore  a 
longitudinal  displacement  (see  page  127). 

Complicated  Fractures. — Comphcations  of  fractures  refer  principally  to 
the  soft  parts.  No  fracture  can  occur  without  some  injury  to  the  surrounding 
parts.  Those  in  which  a  wound  affords  a  medium  of  communication  l^etween 
the  atmospheric  air  and  the  site  of  the  fracture  are  known  as  compound 
fractures.  The  term  "comphcated"  is  now  applied  more  particularly  to 
those  in  which  important  vessels  and  nerves  suffer  injury. 

Compound  Fracture. — The  compound  variety  is  the  most  common  of 
the  complicated  fractures.  Here  the  communicating  wound  involves  both 
skin  and  muscular  tissue,  except  in  situations  in  which  the 
bone  is  subcutaneous.  The  wound  in  compound  fracture 
may  be  caused  by  the  missile  or  object  which  produces 
the  fracture,  as,  for  instance,  the  bullet  in  fractures 
from  gunshot  injuries,  or  the  toe-calk  or  heel-calk  of  a 
horseshoe  in  fractures  resulting  from  the  kick  of  a 
vicious  animal.  Fractures  from  indirect  force  may  also 
be  compound,  the  bone  being  driven  or  pushed  through. 
This  variety  may  be  properly  termed  a  perforating  frac- 
ture. 

Noncommunicating  Wounds  of  the  Skin  in  Frac- 
ture.— Simple  wounds  of  the  skin,  though  not  so  serious 
as  those  which  extend  to  the  site  of  fracture,  are  still 
worthy  of  note.  Suppurative  inflammation  here  may 
prove  serious  from  close  proximity  to  the  bone  lesion. 
During  the  after-course  of  a  fracture  a  skin  wound  may 
arise  as  a  complication,  either  from  faulty  dressing  or, 
in  case  of  delirious  patients,  from  attempts  to  walk.  In  the  former  the 
dangers  relate  principally  to  infection  from  the  neighborhood,  while  in  the 
latter  a  true  perforating  fracture  takes  place. 

Rupture  and  contusions  of  vessels  and  nerves  form  special  comphca- 
tions of  fractures.  In  military  life  these  result  from  gunshot  wounds  particu- 
larly, and  in  civil  life  they  are  more  often  observed  in  machinery  and  railroad 
accidents.     Except  under  these  circumstances  they  are  rare. 

In  case  of  recent  fracture  inspection  in  the  majority  of  cases  reveals  a 
displacement  of  the  fragment.  The  strain  placed  on  the  bone  at  the 
moment  of  giving  way  produces  at  first  a  bend  in  the  same,  owing  to  more  or 
less  flexibility  present  in  all  bones.  The  fracture  occurring,  the  direction  of 
force  which  produces  the  bend  continues,  and  deformity  at  once  results. 
This  displacement  usually  consists  primarily  of  an  angular  flexion  in  the  long 
axis  of  the  bone  (Fig.  25,  A).  Contraction  of  muscles,  the  support  given  to 
fragments  by  surrounding  structures,  the  weight  of  the  portion  of  the  body 
below  the  site  of  fracture,  and  the  rebounding  force  may  individually  or  col- 


FiG   24. — Green-stick 
Fracture. 


INJURIES   AND   DISEASES   OF   BONES 


127 


Icctixcly  opci'ato  to  jirevnit  aii,i;ul;ir  (lis])lacenioiit  in  tiio  long  axis.  Angular 
clis})hu'oniont  failing  to  occur,  other  toi'nis  replace  it,  as  shown  in  Fig.  25. 

The  characteristics  of  each  (lisj)lacement  may  be  seen  at  a  glance.  It 
should  he  remarked,  in  connection  with  the  displacement  shown  at  ]),  that  a 
lengthening  of  the  limb  does  not  occur,  but  that  the  separation  of  the  frag- 
ments is  due  to  muscular  contraction,  the  bony  prominence  to  which  the  mu.s- 
cles  are  attached  being  broken  off. 

Impacted  Fracture. — Among  the  peculiar  forms  of  displacement,  that 
in  which  impaction  occurs  is  to  be  particularly  noticed.  Either  by  external 
force  or  by  the  weight  of  the  falling  body,  one  fragment  is  driven  into  the  other, 
and  an  effect  similar  to  a  gomphosis  is  produced.     Impacted  fracture  occurs 


Fig.  25. — Varieties  of  Displacement  Occurring  in  Fractures. 
A,  Displacement  in  the  axis  of  the  bone;    B,  lateral  displacement;   C,  longitudinal  displacement  with 
transverse  line  of  fracture  and  the  overriding  of  the  fragments ;  D,  longitudinal  displacement  with  separation 
of  the  f  ragnents ;   E'  and  E-,  the  overriding  of  the  fragments  in  oblique  fracture  (modified  after  Hueter) . 


particularly  at  the  junction  of  the  cancellous  structure  and  diaphysis  of  the 
long  bones,  and  is  most  frequently  observed  in  the  neck  of  the  femur  (Fig.  26). 

Rotating  displacement  is  likewise  observed.  This  results  from  the 
rotation  of  a  fragment  on  its  own  axis,  the  fractured  surfaces  remaining  in 
contact  with  each  other. 

Overriding  of  Fragments. — A  combination  of  two  or  more  of  these  forms 
of  displacement  ma}'  be  observed.  A  displacement  in  the  axis,  a  lateral 
displacement,  and  a  longitudinal  displacement  with  approximation  of  the 
fragments,  constitute  the  form  in  which  overriding  occurs  (Fig.  25,  E^. 

Mechanism  of  Displacement. — Whatever  displacement  occurs,  the  prin- 
cipal factors  in  its  production  are  (1)  the  character  of  the  force;  (2)  mus- 
cular contraction.     The  primitive  form,  or  that  of  displacement  in  the  axis,  is  a 


128 


IX.I TRIES    AXD    DISEASES    OF    SEPARATE    TISSUES 


familiar  example  of  the  first  (Fig.  25,  A),  while  the  longitudinal  displacement, 
with  separation  of  the  fragments  (Fig.  25,  D),  illustrates  the  second.  In 
addition  to  these,  two  other  circumstances  enter  into  the  consideration,  i.  c, 
the  weight  of  the  body,  which  is  to  be  considered  in  relation  to  the  occurrence  of 
impacted  fracture,  and  the  weight  of  the  extremity  beyond  the  seat  of  fracture, 
which  may  influence  the  occurrence  of  lateral  and  rotating  displacement. 

Diagnosis  of  Fracture. — The  signs  of  fracture  are  (1)  deformity;  (2) 
swelling,  and  perhaps  contusion  when  the  fracture  is  the  result  of  direct  force, 
and  a  wound  in  compound  fracture;  (3)  pain  and  tenderness;  (4)  crepitus; 
(5)  preternatural  mobility;  (6)  loss  of  function.  Any  of  these  signs  may  be 
absent.  In  examining  a  suspected  fracture  we  employ  chiefly  inspection 
and  palpation. 

Inspection. — The  deformity  vrill  depend  on  the  extent  and  character  of 
-'.  the  displacement  present.     In  addi- 


\' 


tion  to  this,  inspection  reveals  the 
character  of  the  swelling,  the  extent 
of  the  extravasation  of  blood,  and 
the  condition  of  the  skin  at  the 
site  of  fracture.  Later  on,  the 
swelling,  which  in  the  beginning 
depended  on  displacement  of  the 
fragments  and  blood  extravasa- 
tion, will  be  in  a  measure  due  to 
the  formation  of  new  tissue,  bony 
and  otherwise  (see  Repair  of  Bone, 
page  130).  If  the  extravasation  is 
superficial,  the  discoloration  from 
changes  in  the  blood-pigment  will 
occur  early;  if  deeply  situated,  the 
characteristic  blue  and  yellowish- 
green  discoloration  will  appear  after 
the  lapse  of  several  days.  In  case 
a  fracture  extends  into  a  joint  the 
latter  may  become  swollen  from 
serous  effusion  or  a  genuine  hemarthrosis  may  occur. 

Direct  inspection  of  the  injured  bone  may  now  be  accomplished  by  the  aid 
of  the  Rontgen  or  x-ray,  both  for  the  purpose  of  diagnosis  in  doubtful  cases 
and  as  a  guide  for  the  manipulation  in  adjusting  the  fragments,  the  fluoroscope 
being  employed  for  this  purpose.  A  permanent  record  of  the  conditioii  and 
relations  of  the  injured  osseous  structures,  as  well  as  of  the  course  and  completion 
of  the  reparative  process,  is  obtained  by  exposing  a  sensitized  photographic 
plate  to  the  .x-ray,  with  the  injured  part  interposed,  a  shadow  picture  resulting 
(skiagraphy  or  radiography). 

As  a  part  of  the  examination  by  inspection,  mensuration  is  employed  for 
the  purpose  of  assisting  in  the  immediate  diagnosis  and  of  ascertaining  the 
extent  of  shortening  present  when  restitution  of  the  fragments  is  supposed  to 
have  been  accomplished.  In  measuring  the  length  of  a  limb  and  comparing 
it  with  that  of  its  fellow,  care  should  be  taken  to  bear  in  mind  differences  which. 
mav  exist  \\ithin  normal  limits.     Too  much  stress  should  not  be  laid  on 


Fig.  26. 


-Impacted  Intertrochanteric  Fracture 
OF  Neck  of  Femur. 


IX.IURIKS    AXD    DISEASES    OF    BOXES  129 

slijiht  differences,  for  tlie  reason  that,  in  addition  to  the  inal:)ility  to  exckide 
normal  discrepancies,  tlie  method  cannot  be  appHcd  with  sufficient  accuracy  to 
exchide  absokitely  errors  of  a  half  inch  or  less. 

Palpation.— Although  inspection  will  frequently  be  sufficient  to  establish 
the  diagnosis,  in  doubtful  cases  it  is  often  necessary  to  employ  palpation  as  well. 
Tenderness  is  well  marked  at  the  line  of  fracture,  and  this  is  of  special  diag- 
nostic \alue  if  none  exists  elsewkere  in  the  neighborhood.  Crepitus,  a  peculiar 
grating  sound  and  sensation  heard  and  felt  when  the  fragments  moA-e  upon  each 
other,  is  elicited  by  grasping  the  seat  of  fracture  with  both  hands,  one  above 
and  the  other  below,  and  moving  these  in  different  directions.  Slight  rotation 
will  often  elicit  crepitus.  This  sign  is  not  of  so  much  importance  as  was 
heretofore  supposed  by  the  older  surgeons.  It  is  quite  frequently  absent ;  in 
impacted  fracture  it  cannot  be  produced.  In  fracture  with  lateral  displace- 
ment it  is  difficult  to  elicit  it  without  first  reducing  the  fragments,  in 
which  case,  for  purposes  of  diagnosis,  it  is  not  then  necessary-.  The  same 
may  be  said  of  the  longitudinal  displacements.  In  all  of  these  conditions  its 
existence  is  not  necessarv'  for  purposes  of  diagnosis.  On  the  other  hand,  the 
attempt  to  demonstrate  it  is  always  a  source  of  suffering  to  the  patient  and 
it  may  do  positive  damage,  as,  for  mstance,  in  the  case  of  an  impacted  frac- 
ture of  the  cervix  femoris. 

Palpation  likewise  reveals  the  existence  of  preternatural  mobility.  The 
existence  of  a  fracture  undoubtedly  permits  a  certain  amount  of  abnormal 
movement,  and  this  can  be  demonstrated  by  the  same  manipulations  as  are 
carried  on  in  ascertaining  the  presence  or  absence  of  crepitus.  This  sign,  kke 
that  of  crepitus,  is  absent  in  impacted  fracture  and  m  longitudinal  displace- 
ments. In  case  the  fracture  is  near  a  joint,  it  is  exceedingly  difficult  to  dis- 
tinguish between  preternatural  mobility  and  normal  joint  movements. 

The  examination  for  both  crepitation  and  preternatural  mobility  may  well 
be  omitted  until  measures  have  been  taken  for  the  application  of  proper  treat- 
ment in  the  case.  In  some  cases,  such,  for  instance,  as  fractures  of  the 
internal  epicondyle  and  the  malleoli,  sole  dependence  must  be  placed  on  the 
symptoms  of  swelling  due  to  extravasation  and  pain  at  the  site  of  the  injur}-. 

As  a  funher  aid  in  the  diagnosis,  palpation  may  detemiine  the  number, 
size,  and  shape  of  the  fragments.  In  addition  to  this,  later  on  in  the  case,  it 
^^ill  likewise  be  employed  to  ascertain  the  extent  of  functional  disturbance 
of  neighboring  structures,  joints,  etc. 

Anamnesis. — ^^\Tiile  the  historv-  of  the  case  as  obtained  from  bystanders 
may  be  of  some  avail  in  assisting  in  the  diagnosis,  it  should  be  borne  in  mind 
that  statements  made  by  the  injured  person  are  of  but  secondary-  importance, 
and  should  receive  but  little  consideration  compared  vdxh  the  objecti^■e  symp- 
toms. L  nder  all  circumstances  involving  doubt,  if  a  reasonably  well-founded 
suspicion  of  the  existence  of  a  fracture  is  entertained,  the  case  is  to  be  treated 
precisely  as  if  the  diagnosis  were  positively  assured.  It  is  always  best  to  err 
on  the  side  of  safety,  in  the  patient's  interest.  It  is  far  better  for  both  surgeon 
and  patient  that  any  number  of  cases  in  which  a  positive  diagnosis  cannot  be 
made,  and  in  which  only  a  suspicion  of  fracture  is  entertained,  be  treated  as 
fractures,  even  unnecessarily,  than  that  a  single  case  of  fracture  be  allowed  to 
go  untreated  until  irreparable  injury-  is  done.  The  differential  diagnosis 
of  fracture  and  dislocation  will  be  treated  of  under  the  head  of  the  latter. 
10 


130 


INJURIES    AND    DISEASES    OF    SEPARATE    TISSUES 


m 


111 


Course  of  Simple  Fractures. — The  reparative  process  in  simple  frac- 
tures includes  (1)  resorption  of  effused  fluids  and  particles  of  destroyed  tissue; 
(2)  the  formation  of  callus.  The  first  named  is  sometimes  accompanied 
by  slight  fever  (aseptic  fever  of  V  o  1  k  m  a  n  n)  and  some  lymphatic 
swelling  in  the  groin  or  axilla.  During  the  first  few  days  albuminuria  and  the 
presence  in  the  urine  of  debris  from  the  destroyed  red  blood-corpuscles  are 
occasionally  observed  (Riedel).  Fat  embolism,  resulting  from  the  break- 
ing up  of  the  medullary  substance  and  its  absorption  by  the  lymph-channels, 
from  which  it  finds  its  way  into  the  circulation,  is  sometimes  obser\'ed  in 
connection  with  multiple  fractures  or  the  crushing  of  a  single  large  bone.  The 
arrest  of  fat  emboli  in  the  pulmonary  circulation  leads  to  edema  of  the  lungs 
and  consequent  dyspnea,  which  may  terminate  fatalh'. 
The  fat  globules  obstruct  the  capillaries  of  the  glomeruli 
and  are  excreted  with  the  urine.  The  supply  of  fat  may 
be  intermittent  and  occur  at  different  stages  of  the  repair. 

Callus  is  formed  principally  by  the  periosteum  and 
medullary  tissues;  the  former,  how^ever,  plays  the  most 
important  part  in  its  production.  During  the  first  few 
days  calcium  salts  are  deposited  between  the  ends  of  the 
fragments.  In  the  meantime  the  torn  periosteum  becomes 
reunited  and  a  ring  of  new  formation  occurs  at  the  site 
of  the  fracture.  This  is  the  provisional  callus 
(D  u  p  u  y  t  r  e  n) ,  and  is  formed  by  the  innermost  or 
osteogenetic  layer  of  the  periosteum  (Oilier).  At  the 
same  time  the  medullary  substance  forms  the  defini- 
tive callus  (C  r  u  V  e  i  1  h  i  e  r).  The  Haversian  canals 
likewise  take  part  in  the  production  of  bone,  and  to  a 
slight  extent  the  cortical  lamellae  as  well.  The  process  of 
ossification  commences  in  the  newly  formed  tissue  be- 
tween the  fragments;  this  tissue,  together  with  that  fur- 
nished by  the  periosteum  and  medullary  structure,  becomes 
welded  together  in  a  solid  mass,  and  the  formation  of  cal- 
lus is  completed.*  The  length  of  time  which  the  entire 
process  of  repair  occupies  in  man  varies  from  three  weeks 
to  as  many  months.  The  average  time  is  from  five  to  six 
weeks. 

After  the  completion  of  the  reparative  process,  regen- 
eration of  the  callus  (L  o  s  s  e  n)  occurs.  This  consists 
in  a  gradual  restoration  of  the  callus  to  the  condition  of  true  bone.  Sys- 
tems of  regular  lamellae  are  produced,  and  the  dowel  which  divided  the  med- 
ullary cavity  of  the  bone  into  two  portions  is  replaced  by  true  medullary 
substance.  This  process  occupies  a  year  or  more.  In  fractures  involving 
articular  extremities  the  medullary  callus  is  finally  converted  into  true  can- 
cellous structure.  In  fractures  of  the  neck  of  the  femur  the  reformed  cancel- 
lous structure  follows  the  lines  best  calculated  to  bear  the  weight  of  the 
body,  as  in  the  normal  state. 

*  The  terms  "  provisional "  and  "  definitive "  callus  are  liere  retained;  the  terms,  how- 
ever, are  not  quite  exact.  Although  the  outer  ring  is  formed  somewhat  earlier  than  the 
connecting  dowel  from  the  medullary  substance,  j^et  both  alike  contribute  to  the  final 
repair. 


am 


m 


Fic.  27.— Repair  of 
Bone. 
1,  Periosteal  cal- 
lus; 2,  medullary  cal- 
lus or  dowel ;  3,  loos- 
ened periosteum. 


INJURIES    AND    DISEASES    OF    BONES  131 

The  roi-niation  of  callus  ami  its  final  change  to  normal  bone  are  anal- 
ogous to  the  process  of  repair  in  soft  parts  when  union  by  first  intention  occurs. 
The  histologic  processes,  consisting  of  cell  infiltration,  new  formation  of  vessels, 
and  condensation  of  newly  formed  tissue,  are  quite  similar.  The  newly  formed 
bony  tissue  is  the  result  of  the  proliferation  of  existing  osteoblasts.*  The 
manner  in  which  the  periosteal  and  medullary  newly  formed  tissue  appropri- 
ate fioin  the  circulation  the  salts  necessary  for  their  proper  construction  is 
as  yet  unexplahied.  A  curious  circumstance  in  connection  with  this  matter 
is  the  fact  that,  under  the  influence  of  irritation,  particularly  that  of  hematic 
origin  incident  to  extreme  displacement  or  defective  fixation  of  the  fragments, 
the  neighboring  structures  become  the  sites  of  deposits  of  callus.  These 
deposits  are  instances  of  superfluous  callus,  for  the  reason  that  they  take  no 
part  in  either  the  temporary  or  the  permanent  fixation  of  the  fragments. 

Excessive  fonnation  of  callus  is  that  condition  in  which  an  undue  amount 
of  reparative  material  is  formed  at  the  site  of  the  fracture,  and  is  considerably 
in  excess  of  the  requirements  of  definite  repair.  Excessive,  like  superfluous, 
callus  is  the  result  of  undue  mechanic  irritation,  such  as  improper  coaptation 
or  insufficient  fixation  of  the  fragments.  It  is  formed  principally  from  the  osteo- 
genetic  layer  of  the  periosteum  in  transverse  fractures.  The  circumference 
of  the  bone  may  be  two  or  three  times  in  excess  of  the  normal,  this  being  due 
in  part  to  the  displaced  fragments,  and  in  part  to  the  necessity  for  a  large 
mass  of  reparative  material  to  form  bridge-like  masses  of  bone  between  lateral 
surfaces,  in  order  to  maintain  the  weight  of  the  body  in  fractures  of  the  lower 
extremity,  on  the  completion  of  the  process  of  repair  (Fig.  25,  C).  In 
fractures  with  longitudinal  separation  of  the  fragments  an  excessive  amount 
of  callus  at  first  develops  in  filling  up  the  gap  between  the  fragments  (Fig.  25, 
D).  In  oblique  fractures  with  overriding  of  the  fragments  (Fig.  25,  E^  and 
E")  the  excessive  callus  is  produced  by  both  the  medullary  substance  and  the 
periosteum. 

Considerable  impairment  of  function  may  result  from  the  presence  of 
excessive,  as  well  as  of  superfluous,  callus.  The  imprisonment  of  a  nerve-trunk 
may  lead  to  severe  neuralgia  and  paralysis.  This  is  illustrated  in  the  case  of 
the  musculospiral  nerve  in  fractures  of  a  shaft  of  the  humerus.  Functional 
chsability  of  tendons  and  muscles  may  result  from  the  relations  which, 
these  bear  to  excessive  and  superfluous  callus.  Ulceration  of  the  skin  at  the 
site  of  the  injur}'  from  friction  of  bandages  or  clothing  may  also  follow  excessive 
callus. 

Defective  Fonnation  of  Callus;  Pseudarthrosis. — Insufficiency  of  callus 
formation  may  be  relative  or  absolute.  The  first  named  is  due  to  local  dis- 
turbing influences,  while  absolute  defective  formation  of  callus  depends  on 
general  nutritive  disturbances. 

The  causes  of  relatively  defective  callus  formation  are  the  following: 
(1)  Excessive  splintering  or  crushing  of  the  bone.  Here  it  is  impossible  for 
callus  formation  to  occur  until  vascularization  of  the  separate  fragments  has 
taken  place.     Hence  delay,  varying  from  four  to  twelve  weeks,  occurs  in  this 

*  AMiile  it  has  been  asserted  that  the  leukoc}i:es  form  a  new  osteoblastic  cell,  this  is 
probably  not  the  correct  view.  The  traumatic  irritation  reduces  the  bone  to  a  condition 
analogous  to  that  of  young  bone  or  identical  with  it.  This  is  supported  by  the  fact  that, 
very  frequently,  cartilaginous  tissue  is  found  in  the  newly  formed  periosteal  callus. 


132  INJURIES    AND    DISEASES    OF    SEPARATE    TISSUES 

class  of  cases.  It  is  somewhat  rare  for  complete  failure  of  union  to  occur. 
(2)  Impossibility  of  complete  coaptation  of  the  fragments  on  account  of  the 
presence  of  a  parallel  unbroken  bone,  as  in  the  case  of  the  forearm  and  leg. 
Here  each  end  may  form  both  a  periosteal  ring  of  callus  and  a  medullary 
dowel,  but  these  fail  to  reach  each  other  and  unite.  Displacement  longitudi- 
nally, with  separation  of  the  fragments,  will,  in  like  manner,  act  as  a  cause 
of  failure  of  union.  (3)  The  interposition  of  muscle,  tendinous  structures, 
etc.,  as  well  as  the  occurrence  of  profuse  hemorrhage  between  the  fragments, 
also  leads  to  failure  of  union.  (4)  Too  early  movements  of  the  fragments, 
either  through  the  restlessness  of  the  patient  or  through  the  use  of  defective 
retention  apparatus,  may  result  in  the  formation  of  a  synovial  sac  at  the  site  of 
the  fracture. 

These  are  cases  of  pseudarthrosis  in  the  proper  sense,  and  are  to  be  dis- 
tinguished from  cases  in  which  a  simple  movable  connection  between  the  frag- 
ments has  taken  place. 

Other  local  causes  of  pseudarthrosis  and  of  movable  connection  between 
fragments  of  bone  may  occur  without  fracture,  as,  for  i:istance,  in  loss  of  sub- 
stance from  necrosis  following  suppurative  periostitis  and  osteomyelitis. 

The  general  disturbances  of  nutrition  which  produce  absolute  failure  of 
callus  formation  are  included  under  the  following:  (])  Rachitis.  This  may 
simply  retard  the  healing  process,  arrest  it  in  its  progress,  or  prevent  it  alto- 
gether. Antirachitic  treatment  is  indicated.  (2)  General  syphilitic  infec- 
tion may  lead  to  the  replacement  of  the  reparative  process  by  a  syphilitic 
induration.  Antisyphilitic  treatment  will  be  required  before  the  normal  proc- 
esses of  repair  can  proceed.  (3)  The  presence  of  the  cancerous  cachexia, 
the  condition  of  carcinosis,  or  the  local  occurrence  of  malignant  disease.  It 
is  not  always  possible  to  determine  whether  or  not  the  latter  preceded  and  pre- 
disposed to  the  occurrence  of  the  fracture  or'  not.  (4)  Scorbutus  is  said  to 
interfere  with  the  formation  of  callus.  (5)  Pregnancy,  by  withdrawing  the 
lime  salts  from  the  maternal  circulation  in  the  course  of  the  formation  of  the 
fetal  skeleton,  renders  the  formation  of  callus  more  difficult.  (6)  Chronic 
alcoholism  also  interferes  with  the  reparative  process  in  fracture.  (7)  An 
inhibition  of  the  trophic  nerve-fibers,  due  to  injuries  of  the  trophic  centers 
after  spinal  injuries,  or  disturbances  of  them,  interferes  with  the  local 
nutritive  processes  and  thus  iDrings  about  failure  or  retardation  of  union. 
(8)  Infection  and  excessive  suppuration  at  the  site  of  fracture  may  prevent 
the  completion  of  repair.  (9)  The  occurrence  of  an  acute  infectious  fever, 
such   as   typhoid,  may  also  be  mentioned  as  tending  to  prevent  union. 

The  Course  of  Compound  Fracture. — Provided  an  aseptic  condition 
is  maintained  or  an  antiseptic  state  secured,  compound  fracture  may  undergo 
the  process  of  repair  in  the  same  manner  as  a  simple  fracture.  Not  the 
severity  of  the  injury  itself  but  the  absolute  care  which  the  surgeon  bestows 
on  the  case  and  the  relative  susceptibility  of  the  particular  tissues  involved  will 
decide  the  question.  The  difficulties  in  securing  an  antiseptic  condition  are 
caused  by  the  irregular  shape  and  course  of  the  v,^ound  which  leads  to  the 
bone,  as  well  as  by  the  layers  of  loose  connective  tissue  beneath  the  skin  and 
between  the  muscular  aponeurotic  planes  throiigh  which  the  wound  passes, 
since  these  readily  become  the  seat  of  extensive  phlegmonous  inflamma- 
tion.    The  medullary  structure,  particularly  in  young  persons,  is  peculiarly 


INJURIES   AND    DISEASES    OF   BONES  133 

prone  to  a  high  grade  of  plileomonous  inflammation  (acute  septic  osteomyel- 
itis), which,  if  the  patient  escapes  with  his  life,  will  impair  the  usefulness  of 
the  limb  through  failure  or  insufficient  union  of  tlie  fragments.  This  is  par- 
ticularly liable  to  occur  in  comminuted  fracture,  the  supply  of  blood  being 
cut  off  from  the  smaller  fragments  by  the  infiammator\-  process,  so  that  these 
undergo  necrosis.  These  necrotic  fragments  ma\'  become  imprisoned  in  the 
callus,  forming  the  so-called  sequestra.  Callus  may  form  at  some  distance 
from  the  fracture,  where  the  inflammation  is  not  of  so  high  a  grade.  Small 
fragments  Nvhich  have  been  cut  off  from  the  blood-supply,  provided  the  case 
pursues  an  aseptic  course,  may  be  inclosed  bv  callus,  and  maintain  their 
vitality. 

Prognosis  in  Compound  Fractures.— The  prognosis  of  fractures  com- 
plicated with  \vounds  of  the  soft  parts  relates  (1)  to  the  danger  to  life;  (2)  to 
the  integrity  of  the  limb.  Acute  septic  fever  may  destroy  life  in  a  compara- 
tively sliort  time,  or  a  fatal  result  may  follow  chronic  suppurative  fever,  with 
amyloid  degeneration  of  the  alxlominal  organs.  The  function  of  the  limb  may 
be  temporarily  or  permanently  impaired,  or  altogether  destroyed.  This  may 
be  due  to  influences  affecting  the  bone  itself  or  the  surrounding  parts.  Of 
the  former,  may  be  mentioned  the  retardation  of  the  consolidation  of  the  frac- 
ture, the  shortening  of  the  limb  in  consequence  of  removal  of  sequestra  or  frag- 
ments at  the  time  of  injur^^  and  the  disturbances  of  growth  before  the  full 
development  of  the  skeleton.  Suppurative  inflammation  of  an  adjacent 
articulation,  and  disturbances  of  functions  of  muscles  and  tendons  in  the  neigh- 
borhood from  acute  and  chronic  inflammation  of  connective  tissue  planes, 
are  instances  of  the  latter.  Molecular  disintegration  of  the  bony  stmcture,' 
or  caries,  and  death  of  the  bone  en  masse,  or  necrosis,  may  occur.  The 
first  of  these  results  from  inflammatory  granular  proliferation,  the  second  from 
suppurative  inflammation. 

Treatment  of  Simple  Fractures.— Reposition.— When  displacement 
of  the  fragments  is  present,  these  must  be  "reduced,"  or  reposition  effected, 
general  anesthesia  being  employed,  if  necessary,  and  measures  taken  to  secure 
their  retention  as  nearly  as  possible  in  the  normal  position.  When  no  dis- 
placement is  present,  the  latter  alone  will  be  necessary.  The  methods  of 
reduction  to  be  employed  will  vary  according  to  the  part  injured  and  the  char- 
acter of  the  displacement.  Mechanic  aids  to  reduction  are  seldom,  if  ever, 
employed  at  the  present  time,  anesthesia  having  made  them  unnecessary. 

Extension  and  Counter-extension.— Force  in  the  direction  of  the  long 
axis  of  the  limb,  when  peripherally  applied,  is  called  extension;  the  force 
which  opposes  this,  or  makes  traction  in  the. opposite  or  central  direction,  is 
called  counter-extension.  When  muscular  resistance  is  too  great  to  permit 
reduction  by  the  exercise  of  the  surgeon's  unaided  strength,  an  anesthetic 
should  be  administered.  The  latter  should  likewise  be  employed  if  consider- 
able pain  attends  the  examination  or  the  effort  at  reduction. 

Impacted  Fracture.— It  may  be  to  the  patient's  interest  not  to  reduce 
a  fracture,  as,  for  instance,  when  immobilization  has  taken  place  through 
impaction  of  the  fragments,  as  in  fracture  of  the  cervix  femoris  in  an  elderly 
patient,  and  there  is  reason  to  believe  that  permanent  union  through  the  forma- 
tion of  callus  may  follow,  when  otherwise  this  would  be  unlikely  to  occur.  The 
so-called  ''green-stick"  fracture,  however,  though  held  firmly  by  the  inter- 


134  INJURIES   AND    DISEASES    OF    SEPARATE    TISSUES 

denticulation  of  surfaces  of  the  fragments,  will  require  to  be  forcibly  reduced 
in  order  that  the  normal  axis  of  the  limb  may  be  restored. 

Certain  ])ositions  of  the  limb  favor  both  reposition  and  retention.  This 
is  well  illustrated  in  fractures  of  the  clavicle  and  of  the  olecranon  process  of 
the  ulna.  Again,  it  may  happen  that  the  dislocated  portion  cannot  be  made 
to  approach  that  which  is  still  normal,  in  which  case  the  latter  must  be  made 
to  acconmiodate  itself  to  the  former.  Fracture  of  the  upper  third  of  the  femur 
illustrates  this.  Reposition  of  fractured  bony  processes  may  be  assisted  by 
placing  the  joints  in  such  a  position  as  to  relax  the  muscular  structures  attached 
to  them. 

When  a  reduction  is  indicated,  it  must  be  completely  performed  before  a 
retention  apparatus  is  applied.  One  must  not  expect  splints  by  pressure  to 
complete  a  reduction  that  has  been  incompletely  performed. 

Retention  of  the  Fragments. — The  fragments  being  restored  to  their 
normal  position,  it  becomes  necessary  to  apply  such  means  as  will  overcome 
the  tendency  to  redisplacement  arising  from  involuntary  muscular  action, 
from  vohmtary  movements  on  the  part  of  the  patient,  and  from  the  weight 
of  the  parts.  The  apparatus  used  in  simple  cases  consists  of  splints  and 
retentive  bandages.  These  are  applied  to  the  whole  or  a  portion  of  the  limb, 
should  always  include,  when  possible,  the  next  adjacent  articulation  and  suf- 
ficient of  the  circumference  of  the  limb  to  provide  against  movements  of  the 
broken  parts  on  each  other,  and  should  be  made  to  fit  the  various  in- 
equalities of  the  limb  by  systematic  padding.  Injurious  constriction  is  to  be 
guarded  against  on  the  one  hand,  and  a  too  loose  application  of  the  splint 
on  the  other.  As  a  result  of  constriction,  gangrene  from  venous  stasis,  and 
loss  of  the  limb  may  follow.  Failure  to  guard  against  pressure  on  bony 
prominences  sometimes  leads  to  gangrenous  ulceration  at  such  points,  which 
may  extend  to  the  periosteum  and  finally  cause  loss  of  bony  substance.  Too 
loose  an  application  of  the  splint,  on  the  other  hand,  while  it  does  not  lead  to  such 
disastrous  consequences,  gives  rise  to  considerable  pain,  on  account  of  the 
mobility  of  the  fragments,  and  may  be  followed  by  the  occurrence  of  deformity, 
if  not  by  failure  of  union. 

Retention  of  the  fragments  may  be  accompUshed,  under  certain  circum- 
stances, by  means  of  permanent  extension  (Buck).  This  may  also  be 
employed  as  a  measure  of  reduction  by  tiring  out  the  muscles,  as  in  certain 
fractures  of  the  thigh.  The  extending  force  is  usually  applied  below  the  seat 
of  fracture;  in  some  instances,  where  it  is  necessary  to  overcome  the  action 
of  muscles  and  there  is  not  sufficient  space  below  the  fracture  to  apply  the 
plaster  extension  strips,  these  may  be  applied  above  (B  a  r  d  e  n  h  e  u  e  r). 
Very  oblique  fracture  of  the  tibia  and  fibula  low  down  in  the  leg,  in  some  cases, 
can  be  retained  in  no  other  manner.  When  extension  is  substituted  for  splints, 
or  used  in  conjunction  with  them,  provision  must  be  made  for  a  counter- 
extending  force.  The  elevation  of  the  foot  of  the  bed  or  the  use  of  a  perineal 
band  fulfils  this  indication  in  fractures  of  the  lower  extremity.  Weights,  grad- 
uated to  the  requirements  of  the  case,  with  a  friction  roller  or  pulley,  or  elastic 
extension  is  used,  as,  for  instance,  in  fracture  of  the  femur.  After  reduction 
and  the  apphcation  of  retentive  apparatus,  fluoroscopic  inspection  should  be 
employed  to  verify  the  correctness  of  the  apposition,  and  a  skiagraph  of  the 
parts  obtained  for  the  future  protection  of  the  surgeon. 


INJURIES   AND    DISEASES    OF    BONES  135 

Treatment  of  Compound  Fractures. — The  treatment  of  a  fracture 
complicated  with  exposure  of  the  fragments  to  the  atmospheric  air,  is  that  of 
a  simple  fracture,  with  the  addition  of  aseptic  or  antiseptic  treatment  of  the 
wound  of  communication.  'J'horough  disinfection  of  the  parts  must  precede 
the  rethietion.  Some  special  difficnilties  to  be  met,  in  addition  to  those  usually 
encountered  in  ordinary  wounds,  may  be  mentioned  here. 

A  compound  fracture  may  be  infected  through  the  medium  of  foreign 
bodies  containing  infectious  material,  or  the  source  of  infection  may  be  the 
skin  of  the  patient.  On  this  account  the  latter  must  be  at  once  thoroughly 
cleansed  and  shaved  for  a  considerable  distance  around  the  wound.  Most 
foreign  bodies,  even  a  bullet  from  a  firearm,  convey  infection  of  greater  or 
lesser  degrees  of  harmfulness.  The  most  harmful  of  foreign  bodies,  however, 
are  the  pieces  of  clothing,  hair,  straw,  etc.,  which  so  frequently  find  their 
way  into  wounds  of  compound  fractures.  Digital  exploration  is  advisable 
whenever  possible  and  when  the  circumstances  will  permit  thorough  disinfec- 
tion of  the  exploring  finger,  for  only  by  this  means  can  certain  foreign  bodies 
be  distinguished  from  the  contused  soft  parts,  and  the  extent  of  splintering 
and  the  presence  of  detached  fragments  be  determined.  A  sterilized  finger- 
cot  of  thin  rubber  placed  over  the  exploring  finger  is  a  wise  aseptic  pre- 
caution. 

The  removal  of  all  loose  bone  splinters  must  be  the  next  care.  Though 
these  do  not  necessarily  become  necrotic,  still  it  is  better  to  remove  them  when- 
ever possible,  in  order  to  prevent  the  irritation  arising  from  their  presence,  as 
well  as  to  facilitate  drainage  and  to  get  rid  of  the  medullary  substance  which 
may  cling  to  them,  and  which  undergoes  putrefactive  changes  very  rapidly. 

Large  recess  cavities  in  the  depths  of  the  wound  serve  as  an  indication  for 
counter-openings  for  purposes  of  drainage.  When  these  are  made,  they 
should  be  in  a  position  where  gravity  will  aid  in  affording  exit  to  the  wound 
secretions,  and  sufficient  in  number.  It  is  a  mistake  to  suppose  that  a  single 
drain,  in  these  cases,  will  serve  the  purpose.  Every  portion  of  the  cavity, 
in  all  its  recesses,  must  be  thoroughly  cleansed,  irrigated  with  sterile  saline 
solution,  and  either  closed  or  packed  with  antiseptic  gauze,  according  to  the 
indications  in  each  case. 

The  antiseptic  dressings  are  to  be  applied  in  each  case  in  such  a  manner 
as  to  permit  the  employment  of  the  necessary  splints  or  other  retentive 
apparatus. 

Very  small  punctures  of  the  skin  may,  under  certain  circumstances,  be 
simply  cleansed  as  to  surroundings  and  sealed  with  collodion,  to  which  bismuth 
subiodid  or  iodoform  has  been  added.  A  projecting  point  of  bone  should  be 
removed  before  reduction,  in  order  still  further  to  lessen  the  chances  of 
infection. 

The  After=treatment  of  Fractures.— The  fact  that  the  injured  part 
is,  in  a  manner,  hidden  away  from  the  surgeon's  gaze,  and  that  the  frequent 
disturbance  of  the  seat  of  fracture  is  but  a  meddlesome  procedure  and  not 
calculated  to  further  the  patient's  best  interests,  taken  in  connection  with 
the  fact  that  certain  important  deviations  from  the  normal  course  of  repair 
may  arise  and  without  due  care  be  overlooked,  renders  it  important  that  the 
following  precautionary  measures  should  be  taken: 

1.  Inspection  of  the  peripheral  parts  (the  fingers  and  toes),  in  order  to 


136  INJURIES   AND    DISEASES   OF   SEPARATE   TISSUES 

determine  the  presence  of  venous  stasis,  due  to  constriction  from  the  bandage, 
or  inflammatory  swelling  of  the  injured  soft  parts.  This  is  evidenced  by  swell- 
ing and  a  bluish  color.  If  pressure  on  a  toe-nail  or  finger-nail  produces  a 
blanched  appearance  which  is  very  slow  in  changing  again  to  its  former  color, 
the  dressings  are  to  be  removed  immediately  and  reapplied  more  loosely. 

2.  The  occurrence  of  pain  is  the  rule  during  the  first  few  days  following 
the  injury.  This,  however,  is  usually  such  as  can  be  easily  borne  l^y  the 
average  patient.  Should  it,  however,  become  excessive  and  progressively 
increase  in  severity,  the  dressings  are  to  be  removed  and  reapplied.  In  frac- 
tures of  the  leg  special  heed  should  be  given  to  complaints  of  burning  sensa- 
tions or  pain  in  the  heel,  since  an  intractable  pressure  sore  frecjuently  develops 
at  this  point. 

3.  The  indications  arising  from  the  temperature  should  be  carefully  weighed. 
The  resorptive,  or  V  o  1  k  m  a  n  n  '  s  aseptic  fever,  may  exist  during  the  first 
few  days  (see  page  47)  in  simple  fractures,  having  its  origin  in  the  sub- 
stances which  pass  into  the  general  circulation  from  the  place  of  injur}',  such 
as  disintegrated  iDlood-corpuscles,  the  fibrin  ferment  of  the  blood,  and  med- 
ullary fat  from  the  marrow  of  the  injured  bone.  The  aseptic  fever  of  itself 
need  give  rise  to  no  alarm.  Should,  however,  a  temperature  of  102°  to 
103°  F.  be  reached,  it  is  an  indication  for  an  inspection  of  the  parts  and  a 
renewal  of  the  dressing.  Inflammatory  disturbances  may,  under  these  cir- 
cumstances, be  found  to  be  present,  and  the  fever  prove  to  be  a  septic  or 
pyemic  fever,  with  its  focus  at  the  point  of  injury. 

The  ambulatory  treatment  of  fracture  of  the  lower  extremity,  enabling 
the  patient  to  walk  about  with  no  other  aid  than  that  of  the  special  splint 
applied,  is  sometimes  attempted,  with  the  expectation  that  the  patient's 
general  health  will  be  conserved,  the  local  processes  of  repair  stimulated, 
and  more  rapid  and  firmer  union  secured.  The  method  is  not  one  of  general 
applicability. 

In  compound  fractures  freciuent  inspection  of  the  parts  will  be  made 
necessary  by  the  occurrence  of  discharge  or  elevation  of  temperature,  as  above 
described.  Simple  fractures  with  but  slight  or  easily  corrected  displacement 
may  be  allowed  to  remain  uninspected  for  a  period  averaging  about  four 
weeks  from  the  time  of  injury,  unless  the  dressings  loosen  and  require  removal 
on  this  account.  In  very  oblique  fractures  it  is  wise  to  remove  the  dressings 
at  the  end  of  the  second  or  during  the  third  week,  in  order  to  be  certain  that 
the  displacement  has  not  recurred. 

Fractures  in  the  neighborhood  of  joints  in  which  there  is  practically  no 
tendency  to  displacement,  so  that  manipulation  may  be  made,  should  be 
massaged  daily  from  the  commencement.  In  fact,  any  fracture  of  the 
extremities  may  be  treated  in  this  manner  wdth  advantage  where  the  conditions 
present  will  permit  it.  In  all  cases,  where  practicable,  the  patient  should 
not  be  confined  to  bed  any  longer  than  is  necessary,  but  should  be  allowed 
to  move  about  at  the  earliest  possible  moment. 

Treatment  of  the  Functional  Disturbances  Following  Fractures.— 
The  disturbances  of  function  which  follow  union  of  fractures  consist  in  (1) 
edematous  swellings  due  to  circulatory  changes  in  the  parts;  (2)  the  presence 
of  the  residuum  of  the  extravasation;  (3)  adhesions  in  and  about  muscular 
and  tendinous  structures;    (4)  atrophy  of  muscles  from  nonuse;    (5)  interfer- 


INJURIES   AND    DISEASES   OF   BONES 


137 


ence   with    tlio    movements   of   neighboring    joints    from  excessive  callus   or 
hiflammiitory  exudate;  (6)  undue  shortening  of  the  limlj;  (7)  vicious  callus. 

The  first  four  conditions  named  are  benefited  by  massage,  elastic  Ijandages, 
passive  movements,  warm  baths,  electricity,  etc. 

Interference  with  the  movements  of  joints  which  cannot  be  remedied  by 
passive  motion  will  be  described  later  (see  page  161).  Undue  shortening  of 
the  limb  is  to  be  remedied  by  an  extra  thickness  of  sole  on  the  shoe  worn  on 
the  injured  side.  When  partial  union  or  delayed  union  is  encountered,  it  is 
often  well  to  use  various  orthopedic  braces  to  protect  the  limb,  to  shorten  the 
period  of  confinement,  and  to  permit  an  improvement  in  the  general  health, 
which  in  turn  will  often  promote  more  complete  repair  in  the  fracture.  Un- 
united fractures  are  to  be  treated  on  the  hues  laid  down  in  the  section  on 
operations  on  bones.  Amputation  for  these  complications  is  seldom  resorted 
to  at  the  present  day.  In  case  of  joint  disturbances  of  an  intractable  nature, 
particularly  those  of  the  shoulder-joint,  resection  may  become  necessary^  to 
restore  the  function  of  the  limb. 

Osteoclasis,  or  refracture,  may  be  necessitated  by  undue  deformity,  and 
resection  of  the  callus  in  vicious- union  in  which  the  function  of  a  neighbor- 
ing bone  is  interfered  with,  as,  for  instance,  the  radius  and  ulna  in  their  func- 
tions of  pronation  and  supination. 

GUNSHOT  INJURIES  OF  THE  LONG  BONES 

The  destructive  effects  of  the  old  and  new  projectiles  are  alike  severe,  and 
in  certain  localities,  as,  for  instance,  the  femur,  the  injury  inflicted  in  some 
instances  by  the  modern  bullet  is  scarcely  exceeded  by  that  produced  by  the 
old  spheric  missile  of  former  times. 

Owing  to  the  great  resistance  which  compact  bone  offers  to  the  impact  of 
projectiles,  lesions  of  the  diaphyses  in  gunshot  mjuries  are  much  more  exten- 
sive than  in  the  case  of  the  epiphyses  (see  Gunshot  Injuries  of  the  Joints, 
page  147).  In  the  case  of  the  jacketed  bullet  of  high  velocity  and  at  short 
range  the  bone  is  finely  comminuted,  and  the  debris  from  it  is  driven  along 
the  wound  canal.  Bony  fragments  are  torn  loose  from  the  periosteum  and 
increase  the  damage  to  the  soft  parts,  the  bone  being  fissured  in  its  long  axis 
in  both  directions.  The  wound  of  exit  in  the  bone  is  much  larger  than  that 
of  entrance,  showing  the  effect  of  resistance  in  causing  an  explosive  reciprocal 
back-action  on  the  projectile  through  which  a  part  of  its  intrinsic  power  is  con- 
verted into  deformation  (R  e  g  e  r).  At  longer  range  the  missile  is  deprived 
of  a  part  of  its  velocity  before  striking,  as  a  result  of  which  the  perforating 
and  explosive  back-action  effects  are  lessened  and  the  shattering  effect  is 
increased.  The  fragments  are  larger  and  remain  attached  to  the  periosteum, 
and  the  fissures  are  longer.  Under  favorable  circumstances,  <?.  g.,  where  the 
mantle  escapes  injury,  the  resistance  to  the  passage  of  the  missile  is  reduced 
to  the  minimum,  the  tendency  to  tissue  explosion  is  lessened,  and  complete 
perforation  of  the  bone,  together  with  comparatively  slight  comminution  and 
fissuring,  is  observed.  In  other  cases  fracture  without  displacement  occurs. 
Finallyrunder  the  influence  of  a  high  velocity  the  missile  may  strike  a  con- 
cave surface  of  bone,  and,  instead  of  glancing  off,  cut  a  clean  groove  (guttermg 
of  bone). 


138  INJURIES    AND    DISEASES    OF    SEPARATE    TISSUES 

INFLAMMATORY  PROCESSES  IN  BONE 

These  are  primarily  situated  in  the  periosteum  or  the  medullary  cavity, 
while  an  osteitis  proper  is  an  inflammatory  condition  of  the  vascular  canals 
of  the  bone,  with  secondary  changes  in  the  bone  itself  resulting  from  inter- 
ference wdth  its  nutrition. 

Periostitis. — Inflammatory  processes  arising  in  the  periosteum  may  be 
confined  to  this  layer  or  spread  through  the  vascular  channels  to  the  marrow, 
thus  involving  the  whole  bone.  There  are  four  varieties  of  periostitis: 
fibrous,  ossifying,  serous,  and  suppurative. 

Fibrous  periostitis  is  a  connective-tissue  inflammation  resulting  in  a  thick- 
ening of  the  membrane.  It  arises  from  traumatism,  from  continued  irritation, 
from  mild  types  of  bacterial  infection  either  from  contiguous  inflamma- 
tion of  the  soft  parts  or  through  the  circulation.  It  is  a  chronic  process,  and 
if  the  cause  is  long  continued  there  is  a  development  of  new  bone  substance 
among  the  connective-tissue  cells,  so  that  this  becomes  an  ossifying  peri- 
ostitis.    This  is  a  reparative  process,  and  is  seen  in  the  union  of  fractures. 

Serous  periostitis,  or  the  osteitis  albuminosa  of  Oil i  e r  ,  is  of  rare  occur- 
rence. By  some  authorities  it  is  regarded  as  a  distinct  variety,  by  others  as  a 
less  intense  variety  of  the  ordinary  suppurative  type.  While  a  serous,  synovial 
fluid  is  found  beneath  the  periosteum,  tuberculous  or  pus  germs  have  been 
demonstrated  in  the  fluid  in  small  quantities.  The  cases  occur  in  child- 
hood or  in  early  youth,  are  subacute  in  type,  and,  if  lasting  many  weeks, 
show  plainly  that  the  primary  lesion  was  an  osteomyelitis. 

Suppurative  periostitis  as  a  primary  lesion  does  not  occur  after  an  open 
septic  wound  or  as  a  metastatic  septic  process,  yet,  as  a  rule,  it  is  secondary 
to  an  underlying  suppurative  inflammation  of  the  medulla.  This  fact  is 
important  to  bear  in  mind,  else  the  treatment  instituted  wih  not  be  radical 
enough  to  eradicate  the  source  of  the  septic  process. 

The  inflammations  starting  in  the  medullary  cavity  are  of  two  varieties: 
the  suppurative,  usually  acute,  but  often  subsiding  into  a  chronic  stage  after 
drainage  that  is  inadequate,  whether  it  be  spontaneous  or  operative,  and  the 
granulating  type,  usually  chronic  and  due  to  tuberculosis  or  syphilis.  As  a 
result  of  these  inflammatory  processes,  whether  starting  in  the  periosteum 
or  medufla,  certain  changes  may  occur  in  the  bone  itself.  These  consist  of  a 
molecular  disintegration  of  the  bony  structure,  or  caries,  and  death  of  the 
bone  en  masse,  or  necrosis.  The  first  of  these  results  from  inflammatory 
granular  proliferation,  the  second  from  suppurative  inflammation.  These 
terms,  caries  and  necrosis,  were  formerly  used  to  signify  the  disease  of  the 
bone  itself;  it  is  now  a  recognized  fact  that  they  are  simply  conditions  arising 
as  a  result  of  the  inflammatory  state,  caries  from  a  myelitis  granulosa, 
necrosis  from  a  myelitis  and  a  suppurative  periostitis. 

Hyperplastic  Inflammation. — This  is  observed  in  cases  of  excessive 
formation  of  callus,  and  in  the  course  of  arthritis  deformans. 

Tuberculous  Necrosis. — In  addition  to  the  caries  resulting  from  granu- 
lar inflammation,  the  bone  may  die  en  masse.  This  differs  from  the  acute 
necrosis  of  suppurative  inflammation  in  several  ways.  The  mass  is  smaller,  is 
usually  found  at  the  epiphysis  of  the  long  bones  or  in  short  bones,  and  consists 
of  canceflous  tissue.  In  shape  it  often  resembles  a  wedge,  the  base  being 
directed  toward  the  joint.     It  results  from  the  obstruction  of  a  vessel  by  the 


INJURIES   AND   DISEASES   OF   BONES  139 

granular  caries,  and  the  death  of  all  bone  nourished  by  that  vessel.  This 
fonn  is  described  by  Konig  under  the  name  of  "tubercular  infarct." 
Separation  of  the  sequestra  takes  place  much  more  slowly  than  in  the 
case  of  suppurative  inttannnation. 

Inflammation  of  the  Medullary  Tissues ;  Acute  Suppurative  Osteo= 
myelitis.— This  follows  two  types:  (1)  acute  epiphysitis,  usually  in  children; 
(2)  acute  osteomyelitis  of  the  shaft,  usually  from  a  septic  wouna,  as  com- 
pound fracture,  or  through  the  circulation. 

1.  Acute  epiphysitis  attacks  the  nearest  layers  of  medullary  tissue,  which 
are  situated  next  to  the  epiphysial  cartilage.  This  is  in  part  due  to  the  fact 
that  here  the  microorganisms  from  the  blood  find  a  soil  best  suited  to  their 
development.  The  vessels  in  these  localities  assume  the  shape  of  broad  hollow 
spaces  or  lacunae,  in  which  retardation  of  the  blood-current  occurs,  this  of 
itself  favoring  the  arrest  and  lodgment  of  the  cocci  therein.  In  addition,  the 
physiologic  activity  is  greatest  at  this  point,  and  hence  a  predisposition  to 
inflammatory  processes  exists. 

It  is  more  than  probable  that  the  infectious  agent  in  these  cases  is  Staphy- 
lococcus pyogenes  aureus  (see  page  26),  as  shown  by  the  observations 
of  L  ii  c  k  e  and  Recklinghausen,  and  that  this  finds  its  way 
into  the  circulation  through  the  mucous  membrane  of  the  respiratory  pas- 
sao-es  and  digestive  tract,  inflammatory  disturbances  of  these  structures  fre- 
quently preceding  the  onset  of  the  disease  in  question.  For  example,  folli- 
cular tonsillitis  is  often  the  primary  source  of  infection  (Kocher). 
That  the  disease  does  not  directly  invade  the  joint  structure  is  due  to  the 
absence  of  vascularity  of  the  epiphysial  cartilages.  It  is  readily  propagated  in 
the  direction  of  the  periosteum,  along  the  blood-vessels,  at  which  point  it  meets 
with  the  subperiosteal  connective  tissue.  The  disease  thereafter  pursues  a 
course  partly  within  the  medullary  tissue  and  cancellous  structure,  and,  pro- 
ceeding through  the  bone  by  way  of  the  vascular  canal,  partly  in  the  subperi- 
osteal connective  tissue,  or  intima  of  the  periosteum.  The  suppurative  process 
now  makes  its  way  through  the  latter,  and  an  abscess  invading  the  soft  parts 
surrounding  the  bone  follows. 

Constitutional  disturbances  more  or  less  pronounced  accompany  the  prog- 
ress of  the  disease.  In  the  hyperacute  type  the  temperature  may  reach 
105°  F.,  or  even  higher.  This  may  be  preceded  by  a  chill  or  a  succession  of 
rigors.  Dehrium  or  coma  may  supervene  and  the  patient  perish  from  the  vio- 
lence of  the  general  symptoms  before  the  local  conditions  are  sufficiently  dis- 
tinctive to  attract  the  attention  of  the  medical  attendant,  particularly  in  the 
case  of  very  young  children,  from  whom  it  is  difficult  to  obtain  a  satisfactory 
history  as  to  locahzed  pains,  etc.  Again,  the  disease  may  run  a  prolonged 
course,  simulating  typhoid  fever.  Pneumonia,  probably  of  metastatic  origin, 
is  a  not  infrequent  complication. 

The  local  symptoms,  except  the  occurrence  of  pain,  are  not  distinctive  in  the 
beginning.  The  occurrence  of  localized  edema  is  the  first  objective  sign  of 
the  source  of  the  disturbance,  this  preceding  the  appearance  of  the  abscess. 
After  the  opening  of  the  latter,  whether  artificially  or  spontaneously,  the  dis- 
turbances of  nutrition  in  the  bone  become  apparent.  Necrosis  is  discovered 
to  exist,  this  being  either  locahzed  or  affecting  the  entire  bone,  according  to 
the  extent  of  the  necrotic  process.     The  separated  portions  of  bone  are  called 


140  INJURIES   AND    DISEASES    OF    SEPARATE    TISSUES 

sequestra,  and  these  are  called  total,  cortical,  or  central,  these  terms  corre- 
sponding respectively  to  the  extent  and  the  location  of  the  separated 
portions.  The  separation  of  the  periosteum  by  the  invasion  of  pus  beneath 
its  surface  is  not  necessarily  followed  by  the  destruction  of  its  osteogenetic 
properties.  In  this  case  a  new  formation  of  bone  occurs,  and  the  latter, 
imprisoning  a  sequestrum,  is  called  the  involucrum.  Here  and  there 
on  the  surface  of  the  periosteum  the  bone-forming  jDroperty  of  the  latter 
is  destroyed,  or  the  periosteum  has  given  way  under  the  pressure  from 
within.  Here  failure  of  new  formation  of  bone  occurs,  and  openings  lead 
through  the  periosteum  and  involucrum  to  the  sequestrum  within  the  latter. 
These  openings  are  known  as  cloacae.  The  abscess  cavity  in  the  soft  parts 
contracts,  after  escape  of  its  contents,  and  the  channel  of  communication  with 
the  diseased  bone  beneath  is  called  a  fistula. 

While  the  inflammatory  process  does  not  invade  the  neighboring  joints 
directly  by  vascular  communication,  on  account  of  the  protection  which  the 
epiphysial  cartilage  affords,  yet  the  separation  of  the  latter,  together  with 
that  of  the  epiphysis  from  the  diaphysis,  by  the  suppurative  process,  leads  to 
the  invasion  of  the  joint,  and  a  suppurative  arthritis  results. 

2.  The  acute  osteomyelitis  secondary  to  compound  fractures  is  less  com- 
mon since  the  antiseptic  treatment  of  such  cases  has  been  used.  The  lesion 
is  the  same  as  has  just  been  described.  The  symptoms  are  those  of  septic 
infection;   death  may  result  from  septicemia. 

Treatment. — ^Treatment  directed  to  the  arrest  of  the  disease  by  means  of 
free  incisions  can  scarcely  affect  the  medullary  infection,  except  possibly  by  the 
effect  produced  by  antiseptic  agents  conveyed  to  the  parts  from  the  periosteal 
involvement.  When  free  incision  fails  to  reveal  the  presence  of  a  sufficient 
amount  of  disease  to  account  for  the  symptoms,  the  chiseling  away  of 
a  portion  of  the  bone,  in  order  to  reach  the  central  point  of  infection,  is 
demanded.  After  large  abscess  cavities  have  formed  in  the  soft  parts, 
free  incision  and  antiseptic  treatment  of  their  interiors  fulfil,  for  the  time 
being,  all  the  indications.  Attempts  to  resect  svich  portions  of  bone  as 
have  been  denuded  by  the  separation  of  the  periosteum  have  not,  thus  far, 
been  followed  by  very  encouraging  results.  As  soon  as  the  diagnosis  of  an 
acute  osteomyelitis  is  made,  even  within  the  first  day  or  two  of  the  disease, 
it  is  wise  not  only  to  incise  the  periosteum,  but,  by  chisel  or  trephine,  to  open 
the  medullary  cavity.  Though  pus  has  not  yet  formed,  the  acute  sepsis  is 
relieved,  and  not  only  is  life  saved  in  the  more  severe  cases,  but  even  when 
the  symptoms  are  less  alarming,  the  local  process  is  arrested  and  less  bone  dies. 
Thus  the  extensive  destruction  often  observed  in  the  late  cases  is  avoided. 
Though  a  second  operation  for  removal  of  sequestra  or  caries  may  be  indi- 
cated in  two  or  three  months,  this  is  less  extensive  than  if  the  primary  drainage 
of  the  medullary  cavity  had  been  omitted. 

The  separation  of  portions  of  bone  is  an  indication  for  immediate  opera- 
tive interference.  Should  the  sequestra  be  sufficiently  small  to  be  removed 
through  the  fistulous  channels,  extraction  may  suffice.  If  not,  the  operation 
of  sequestrotomy  must  be  resorted  to  (see  page  369).  The  granulating 
process  sometimes  crowds  a  sequestrum  to  the  surface;  quite  large  cortical 
sequestra  are  thus  spontaneously  expelled.  The  fact  that  sequestra  are  some- 
times dissolved  by  the  granulations  led  to  the  attempt  to  imitate  the  process. 


INJURIES   AND    DISEASES    OF   BONES  141 

and  lactic  acid  was  employed  for  this  purpose.  Later,  the  application  of  pep- 
sin and  hydrochloric  acid  was  suggested  (Morris).  The  researches  of 
Tillmanns  seem  to  indicate  that  the  carbonic  acid  of  the  blood  serves 
to  dissolve,  to  some  extent,  the  necrotic  bony  tissue.  The  best  of  the  means 
employed  for  this  purpose,  however,  are  inferior  to  operative  interference. 

Myelitis  Granulosa. — Granulating  inflammation  of  the  medullary  tissue 
of  bone  is  due,  in  the  great  majority  of  cases,  to  the  infection  of  either  tul^ercu- 
losis  or  syphihs.  It  may  be  either  a  primary  or  a  secondary  tuberculous  mani- 
festation. The  tubercle  bacillus  does  not  choose  necessarily  the  young  layers 
of  the  medullary  tissue,  as  do  the  infectious  agents  of  suppurative  osteomyel- 
itis, but  selects  any  bony  structure  consisting  of  a  relatively  large  amount  of 
medullary  tissue,  such  as  the  bodies  of  the  vertebra,  the  bones  of  the  tarsus, 
carpus,  etc.  Irritation  of  the  medullary  structure  follows  the  presence  of  the 
bacillus,  and  a  slow  granulating  process  is  inaugurated ;  absorption  of  the  can- 
celli  follows,  the  granular  foci  coalesce  and  the  cortical  layer  is  destroyed  to  a 
greater  or  lesser  extent.  Suppuration  finally  occurs  in  the  foci  of  deposit,  which 
finds  its  way  to  the  surface  through  destruction  of  the  cortical  layer,  and  an 
abscess  makes  its  appearance.  This  abscess  differs  from  the  acute  form  char- 
acteristic of  suppurative  osteomyelitis  in  being  very  slow  in  its  course,  distinctly 
circumscribed,  and  in  having  no  tendency  to  involve  surrounding  parts  (cold 
abscess).  These  abscesses  occasionally  become  infected  with  the  pus  organ- 
isms and  run  an  acute  course.  In  case  the  bone  is  attacked  in  the  neighbor- 
hood of  a  joint  and  perforation  takes  place  in  the  direction  of  the  latter,  a 
synovitis  hyperplastica  granulosa  occurs.  A  granulating  tenosynovitis 
may  likewise  occur  from  involvement  of  the  tendinous  sheath.  The  pus  usually 
makes  its  way  to  the  surface  sooner  or  later,  and  is  discharged  either  by  ulcera- 
tive action  or  through  an  incision;  it  may,  however,  remain  at  its  original 
point  of  formation,  thus  constituting  a  bone  abscess.  These  bone  abscesses 
are  prone  to  occur  near  the  articular  extremity  of  a  bone,  particularly  near 
the  head  of  the  tibia  and  at  the  olecranon  process  of  the  ulna.  Sequestra  are 
rather  infrequently  formed ;  when  these  do  occur,  they  are  insignificant  com- 
pared with  those  present  in  suppurative  osteomyelitis.  Fistulous  openings 
may  communicate  with  the  broken-down  granular  focus,  and  the  granulations 
themselves,  when  exposed  to  view,  are  found  to  be  of  a  grayish-yellow  color ; 
they  have  no  special  tendency  to  cicatrization.  Microscopic  examination  shows 
numerous  groups  of    microorganisms  and  sometimes  real  tubercle   as  well. 

The  course  of  the  disease  differs  in  several  important  particulars  from  that  of 
the  disease  last  described.  The  febrile  symptoms  are  less  marked.  At  night  the 
elevation  of  temperature  may  not  reach  more  than  a  single  degree  above  the 
normal.  The  destructive  process  in  the  bone  is  always  in  the  direction  of  caries 
rather  than  in  that  of  necrosis.  While  suppurative  osteomyelitis  may  prove  a 
dangerous  affection  in  the  beginning,  particularly  in  children,  the  disease  under 
consideration  presents  few  alarming  features  in  its  incipiency.  This  is  com- 
pensated for,  however,  by  the  serious  after-course  of  the  affection.  Both  may 
be  complicated  by  amyloid  degeneration  of  the  abdominal  organs,  but,  in  the 
granulating  form,  there  exists  the  special  danger  of  general  tuberculosis. 

The  tuberculous  deposit  which  may  occur  either  as  a  circumscribed  nod- 
ular product,  or  as  tuberculous  infiltration  in  cases  of  myelitis  granulosa,  is 
converted  into  yellow  tubercle  by  the  process  known  as   caseation.     This 


142  INJURIES   AND    DISEASES   OF   SEPARATE   TISSUES 

process  is  analogous  to  fatty  degeneration  but  not  identical  with  it.  It  is  the 
result  of  the  presence  of  the  bacillus  of  tuberculosis  or  its  ptomains,  and  is 
preceded  by  coagulation  necrosis.  Softening  occurs  coincidentally;  a  number 
of  these  cheesy  foci  may  become  confluent  and  form  a  large  caseous  center. 
The  bacillus  cannot  be  found  in  these,  having  perished  from  starvation, 
but  experimental  inoculations  show  the  cheesy  material  to  be  infectious. 
This  is  due  to  the  presence  of  the  spores,  which  remain  in  an  active  condition. 

Treatment. — The  use  of  remedies  directed  against  the  tubercle  bacillus 
in  the  treatment  of  the  diseased  focus  has  been  attempted.  Among  the  first 
of  these  employed  may  be  mentioned  carbolic  acid  in  solution  (from  3  to  5 
per  cent),  suggested  by  H  u  e  t  e  r  ,  and  Landerer's  arsenious  acid 
injections.  More  recently  encouraging  results  have  been  obtained  by  the  use 
of  a  10  per  cent  emulsion  of  iodoform  in  glycerin  or  balsam  of  Peru 
(S  e  n  n),  and  a  5  per  cent  alkahne  emulsion  of  cinnamic  acid  (L  a  n  - 
clerer).  In  the  case  of  iodoform,  which  has  given  good  results,  it 
is  not  definitely  known  whether  the  curative  effects  are  due  to  the  iodoform 
as  such  or  to  the  formic  acid,  which,  it  is  claimed,  is  one  of  the  products  of 
the  decomposition  of  this  agent  in  the  tissues.  The  injections  may  be  made 
every  two  weeks,  and  from  one-half  to  one  ounce  of  the  emulsion  injected  at 
each  seance. 

Ignipuncture. — Deep  cauterizations  were  employed  (R  i  c  h  e  t  ,  1870) 
by  means  of  a  narrow  platinum  pointed  cautery-iron.  K  o  c  h  e  r  ,  inde- 
pendently of  R  i  c  h  e  t  ,  employed  the  method,  but  considered  its  use 
mdicated  particularly  in  recent  cases.  The  Paquelin  cautery  is  a  better 
instrument  for  the  purpose.  The  operation  should  be  performed  under  strict 
aseptic  precautions.  The  compact  bone  is  usually  softened  sufficiently  to 
permit  the  point  to  penetrate  to  the  tuberculous  focus.  The  tunnel  or  channel 
thus  made  should  be  dressed  with  iodoform. 

Chiseling  and  Evidement. — These  may  be  employed  in  all  stages  of  the 
disease.  They,  together  with  typic  resection  or  amputation,  constitute  the  rad- 
ical treatment  of  the  disease.  In  these  tuberculous  lesions  special  attention 
should  also  be  paid  to  general  medication,  diet,  and  hygiene,  as  important 
adjuncts  to  the  surgical  procedures  indicated. 

Syphilitic  Affections  of  Bone. — These  belong  to  the  so-called  tertiary 
stage  of  the  disease.  With  our  present  knowledge  of  the  necessity  for  pro- 
longed treatment  in  the  earlier  stages  of  syphilis,  they  are  somewhat  less 
common  than  formerly. 

Syphilitic  Osteomyelitis. — Granular  inflammation  of  the  medullary  tissue 
as  a  result  of  syphihs  is  comparatively  rare.  It  sometimes  attacks  the  pha- 
langes of  the  fingers  and  toes,  particularly  in  the  congenital  form  of  the 
disease.  In  the  rare  cases  in  which  syphilitic  granulating  inflammation  of  the 
marrow  of  long  bones  occurs,  the  infected  foci  are  present  in  considerable 
numbers.  The  course  of  this  disease  is  somewhat  similar  to  that  pursued 
when  the  disease  is  due  to  tuberculous  infection.  The  bone  is  usually  con- 
siderably condensed  in  the  neighborhood  of  the  foci,  and  the  sequestra  are, 
as  a  rule,  inclosed  by  solid- walled  involucra. 

Syphilitic  Periostitis. — This  commences  as  a  flattened  swelling  or  gumma. 
The  favorite  sites  are  the  anterior  border  of  the  tibia,  the  ulna,  radius,  clavicle, 
and  the  frontal,  parietal,  and  occipital  bones.     These  being  the  most  exposed 


IXJURIKS    AXI)    DISEASES    OF    BONES  143 

to  injury,  it  would  seem  as  if  traumatism  acted  as  an  exciting  cause.  The 
periosteum  is  invaded  by  soft  granulating  tissue,  which  forms  the  flattened 
swellings  or  gummas;  the  membrane  becomes  thickened,  the  nutrition  of  the 
bone  is  interfered  with,  and  destruction  of  the  latter  follows.  Under  anti- 
syphilitic  treatment  these  swellings  frequently  disappear,  leaving  either  a  bony 
defect,  or  an  ele\-ation  the  result  of  an  ossifjdng  periostitis,  at  the  site  of  the 
former  gumma.  Suppuration  and  ulceration  of  the  overlying  skin,  with 
necrosis,  is  the  rule  in  untreated  cases.  The  skull  is  specially  predisposed 
to  the  multiple  form  of  the  affection. 

Diagnosis. — AVhen  the  history  of  a  primar}-  sore,  or  that  relating  to  the 
secondary  manifestation  of  the  disease,  can  be  obtained,  the  diagnosis  is  not 
difficult.  In  the  absence  of  these,  .syphilis  of  bone  must  be  differentiated  from 
tuberculous  disease.  In  the  skull,  and  the  fingers  and  toes,  tuberculous  bone 
disease  is  not  so  likeh'  to  be  multiple  as  syphihs  of  bone.  In  the  latter  the 
destructive  processes  are  in  the  direction  of  necrosis  rather  than  in  that  of 
caries.     The  microscope  may  be  made  available  in  the  differential  diagnosis. 

Treatment. — The  therapeutic  indications,  as  far  as  internal  medication 
is  concerned,  are  those  of  sypliilis.  The  local  treatment  consists  in  free 
incision,  thorough  scraping  and  disinfecting  by  means  of  a  1 :  1000  solution  of 
chlorid  of  zinc.  Necrotic  portions  of  bone  must  be  removed,  by  chisehng, 
if  necessary. 

Actinomycosis. — The  actinomyces,  the  specific  organism  of  this  disease, 
is  described  on  page  209.  It  attacks  the  bones  and  adjacent  parts,  as  well 
as  other  tissues  of  the  bod}'.  The  lower  animals  (oxen,  horses,  swine,  etc.) 
are  affected  by  it  as  well.  A  clironic  soft  granulating  inflammation  occurs 
at  the  site  of  the  infection,  which  gradually  changes  to  a  hard  swelling.  The 
exterior  of  this  is  formed  of  calluslike  connective  tissue,  but  the  interior  is 
made  up  partly  of  smaU  suppurative  foci  and  partly  of  suppurative  canals; 
in  the  semiliquid  contents  of  these  canals,  peculiar  bodies  having  a  diameter 
of  2  mm.,  either  colorless  and  diaphanous,  or  opac^ue  and  white,  yellow, 
brown,  or  green,  and  visible  to  the  naked  eye,  are  found  floating. 

In  all  probability  the  fungus  fuids  its  way  into  the  human  body  with  the 
food.  It  is  sometimes  found  in  carious  teeth  and  in  the  crypts  of  the  tonsils. 
The  most  frequentty  selected  site  of  actinomycotic  inflammation  is  the  lower 
jaw.  Hard  and  immovable  swellings  occur  on  the  bone,  differing  from  those 
of  common  periostitis  by  their  slower  growth  and  peculiar  doughy  character. 
Suppuration  mth  discharge  of  pus,  usually  into  the  cavity  of  the  mouth,  fol- 
lows. The  actinomyces  may  be  demonstrated  in  the  pus.  In  other  cases 
the  entire  submaxillaiy  bone  may  become  invaded,  Mith  involvement  of  the 
neighboring  soft  parts  in  the  doughy  swelling,  without  well-defined  boundaries. 
Fistulous  openings  lead  to  the  diseased  bone.  The  infection  ti'avels  along  the 
connective-tissue  spaces,  hence  the  h-mphatic  glandular  structures  are  not 
involved.  In  this  mamier  it  may  reach  the  anterior  portion  of  the  A-ertebral 
column  in  the  cervical  region.  The  suppm'ative  process  is  not  an  essential 
product  of  the  actinomycotic  inflammation,  but  rather  the  result  of  the 
invasion  of  suppurative  cocci. 

Diagnosis. — This  can  be  made  positively  only  by  the  recognition  of  the 
before-mentioned  bodies  by  aid  of  a  microscopic  examination.  In  suspicious 
cases  an  exploratory  incision  is  justified. 


144  INJURIES    AND    DISEASES    OF    SEPARATE    TISSUES 

Prognosis. — In  the  beginning  of  accessible  foci,  free  incision  and  ener- 
getic treatment  may  arrest  tlie  disease.  Once  the  connective  tissue  is  invaded, 
however,  the  case  is  almost  hopeless,  the  patient  succumbing  to  the  slowly 
progressive  suppurative  process,  with  its  accompanying  amyloid  degeneration 
of  the  abdominal  organs. 

Treatment. — Early  incision,  free  curetting  with  Vblkmann's  sharp 
spoon,  and  subsequent  thorough  disinfection  of  all  the  parts  by  means  of  a  10 
per  cent  solution  of  chlorid  of  zinc,  constitute  the  only  trustworthy  means  of 
relief  at  our  command.  The  condensed  connective  tissue  which  forms  the  outer 
or  shell  portion  of  the  nodules  should  be  dissected  away,  as  it  sometimes  contains 
the  infective  agent,  and,  if  permitted  to  remain,  may  lead  to  recurrences. 

Rachitis  is  a  constitutional  disease,  but  the  important  lesions  and  symp- 
toms occur  in  the  bones.  It  is  essentially  a  disease  of  malnutrition.  This 
may  result  from  poor  assimilation  and  intestinal  disorders  in  the  children  of 
the  rich,  but  more  frequently  from  improper  food  and  hygiene  in  the  children 
of  the  poor.  It  usually  begins  in  infancy.  It  is  very  common  in  Europe, 
less  so  in  America.  It  consists  of  a  defective  deposit  of  lime  salts  and  a 
hyperplastic  proliferation  of  the  cartilaginous  and  periosteal  structures  at  the 
extremities  of  growing  bones.  The  earlier  symptoms  are  those  of  intestinal 
catarrh,  irregular  dentition,  and  a  delay  in  the  closure  of  the  fontanels  with 
a  thinning  of  the  cranial  bones,  or  craniotabes.  At  this  stage  perspiration 
about  the  neck  is  well  marked. 

Diagnosis. — The  special  characteristics  of  the  disease  for  diagnostic  pur- 
poses are  the  peculiar  enlargements  of  the  ends  of  the  bones.  These  may  be 
fusiform  or  ringlike.  At  the  anterior  extremities  of  the  ribs  these  enlargements 
form  the  so-called  "rachitic  rosar5^"  A  peculiar  curve  extending  from  the 
level  of  the  ensiform  cartilage  toward  the  axilla  and  corresponding  to  the 
insertion  of  the  diaphragm  (Harrison's  groove)  is  diagnostic.  The 
lower  ends  of  the  radius  and  fibula  are  specially  affected,  forming  a  trans- 
verse swelling  at  these  points.  In  the  case  of  the  sutures  of  the  skull,  these 
appear  as  flat  prominences. 

Of  the  vast  number  of  conditions  resulting  from  this  disease  of  the  general 
skeleton,  the  most  important,  from  the  surgical  standpoint,  are  the  subperi- 
osteal fractures,  the  retardation  of  callus  formation,  and  certain  deformities 
at  the  joints  and  in  the  shafts  of  long  bones.  These  will  be  considered  under 
their  appropriate  heads. 

General  Treatment. — The  general  treatment  of  rachitis  consists  in  sup- 
plying the  patient  with  wholesome  food  and  pure  air.  The  diet  should  con- 
sist mainly  of  milk,  eggs,  and  meat.  The  phosphate  and  carbonate  of  lime 
and  ferruginous  tonics  are  to  be  prescribed.  The  administration  of  pure  phos- 
phorus and  cod-liver  oil  is  also  of  service.  The  tendency  to  intestinal  catarrh 
should  be  borne  in  mind. 

Osteomalacia. — As  distinguished  from  rachitis,  this  disease  is  character- 
ized by  a  softening  of  the  fully  developed  bone.  It  is  endemic  in  .certain 
regions  (the  Rhine  and  its  tributaries,  Alsace,  Flanders,  and  Westphalia).  It 
is  almost  exclusively  limited  to  the  female  sex  during  the  period  of  preg- 
nancy. Its  occurrence  is  favored  by  unwholesome  food,  damp  places  of  resi- 
dence, and  privations  of  different  kinds. 

In  the  puerperal  condition  the  pelvic  bones  are  primarily  involved,  and 


INJURIES    AND    DISEASES    OF    BONES  145 

the  disease  is  fiV(|uently  resliic-tcd  to  tlic'sc.  '\'\\v  lower  and  upper  extremities 
and  vertebral  column  may  become  affected,  particularly  untler  the  influences 
of  repeated  pregnancies.  Idie  nonpuerperal  form  oiiginates  generally  in  the 
bodies  of  the  vertebra,  extending  to  the  bones  of  the  upper  extremity,  skull, 
chest  walls,  pelvis,  and  lower  extremities.  The  disease  consists  essentially  of 
a  softening  of  the  bone  by  a  decalcifying  process,  the  primary  origin  of  which 
has  not  been  discovered. 

The  bones  become  bent  and  otherwise  chstorted,  and  fractures,  either  par- 
tial or  complete,  occur.  The  carrying  of  burdens  by  pregnant  women  afflicted 
with  the  disease  favors  distortions  of  the  pelvic  bones.  Cesarean  section  is 
frecjuently  necessitated  by  the  presence  of  the  latter. 

Diagnosis. — In  the  early  stages  of  the  disease  the  symptoms  are  not  suf- 
ficiently distinct  to  suggest  its  presence.  The  peculiar  rending  pains  are 
usually  attributed  to  rheumatic  affections  of  the  bones  and  muscles.  The 
characteristic  deformities  alone  denote  the  true  character  of  the  affection. 

Prognosis. — The  prognosis  is,  as  a  rule,  very  unfavorable.  Recovery 
rarely  takes  place. 

Treatment. — There  is  practically  no  treatment  other  than  that  relating  to 
favorable  hygienic  influences.  Alterative  tonics  may  be  prescribed,  and  salt 
baths,  together  with  nutritious  food.  Women  in  the  child-bearing  age 
should  be  warned  of  the  dangers  which  attend  pregnancy  occurring  in  the 
course  of  this  disease. 

Osteopsathyrosis  or  Rarefying  Osteitis. — In  this  affection  an  abnor- 
mal brittleness  of  the  bone  exists.  Those  layers  of  the  cortical  portion 
adjacent  to  the  medullary  canal,  as  well  as  the  cancelli,  disappear,  and  the  med- 
ullar}^ lacunae  become  enlarged  and  filled  with  yellow  fatt}^  marrow  (lipoma- 
tosis). It  is  the  common  form  of  senile  atrophy  of  bone,  and  that  which  pro- 
duces many  of  the  fractures  occurring  in  old  age,  as  well  as  those  of  tabes  and 
paralysis  (Charcot),  with  an  insufficient  or  trifling  traumatism.  The 
striking  absence  of  pain  following  these  fractures  will  at  once  suggest  their 
cause.  This  osteopsathyrosis  tabetica  occurs  only  after  the  disease  of  the 
spinal  cord  is  far  advanced.  The  failure  of  the  paralyzed  muscles  to  support 
properly  the  shafts  of  the  bones  also  favors  the  occurrence  of  fracture. 

Tabetic  fractures  may  unite,  as  other  fractures,  by  proper  treatment.  Even 
large  deposits  of  callus  may  be  favored  by  movements  in  patients  insensible 
to  pain. 

Sarcoma  of  Bone. — This  occurs  as  periosteal  sarcoma  and  central  sar- 
coma. 

Periosteal  sarcomas  occur  comparatively  early  in  life,  and  their  occur- 
rence is  not  infrequently  referred  to  sorne  preceding  injury.  They  affect  by 
preference  the  articular  extremities.  When  springing  from  the  shaft,  the  growth 
may  be  restricted  to  a  portion  of  the  circumference,  or  form  a  fusiform  swelling 
enveloping  the  entire  bone.  The  bone  itself,  however,  becomes  ultimately 
affected  through  the  Haversian  canals.     The  joints  are  rarely  involved. 

The  cellular  elements  of  periosteal  sarcomas  may  be  either  round  or  spindle- 
shaped.     These  growths  are  especially  prone  to  calcification  and  ossification. 

Central  sarcomas  occur  in  individuals  from  ten  to  forty  years  of  age,  and 
are  more  freciuently  observed  near  the  articular  extremities  of  the  long  bones; 
exceptionally  the}'  may  arise  from  the  middle  of  the  shaft.  In  the  former 
11 


146  INJURIES    AND    DISEASES    OF    SEPARATE    TISSUES 

situation  they  are  spindle-celled,  in  the  latter  round-celled.  The  long  bones 
of  the  lower  extremity  are  affected  by  preference.  Joint  cavities  are  rarely 
invaded,  and  adjoining  lymphatic  glands  are  only  exceptionally  involved. 
The  cells  may  advance  along  the  Haversian  canals,  and  a  tumor  form  on 
the  external  surface  of  the  bone  beneath  the  periosteum.  Enlargement  of 
the  bone  also  takes  place  from  an  encroachment  of  the  growth  on  its  bon}^ 
walls,  which  finally  give  way,  and  there  results  as  one  of  the  clinical  phenomena 
a  strong  rhythmic  pulsation  and  bruit. 

THE  JOINTS 

Contusions  of  the  Joints. — Joints  in  which  the  capsule  is  in  close  rela- 
tion with  the  bony  surfaces  on  the  one  side  and  the  integument  on  the  other 
(the  knee-joint,  phalangeal  joints  in  flexion,  etc.)  may  be  the  site  of  severe  con- 
tusion, or  even  a  tearing  of  the  capsule.  Hemarthrosis  is  a  not  infre- 
quent consequence  of  contusion  of  a  joint.  The  hemorrhage  into  the  joint 
may  arise  from  an  injured  vessel  in  the  capsule  or  its  immediately  overlying 
structures  (articular  arteries  in  case,  of  the  knee-joint,  etc.),  or  there  may  be 
a  tearing  off  (fracture)  of  a  portion  of  the  bone  inclosed  by  the  capsule  or 
attached  to  it,  the  hemorrhage  resulting  from  the  vessels  in  the  bone. 

Syraptoms. — A  swollen  condition  of  the  joint  ensues  on  the  occurrence  of 
the  accident,  sometimes  accompanied  by  subcutaneous  and  subfascial  hemor- 
rhage. When  no  subcutaneous  hemorrhage  complicates  a  hemarthrosis,  the 
joint  is  not  chscolored.  If  sufficient  blood  has  been  effused  into  the  joint, 
fluctuation  may  be  present.  The  interposition  of  thick  soft  parts,  or  ex- 
treme tension  due  to  a  large  amount  of  blood,  may  mask  this  symptom.  The 
fluctuation  felt  at  first  gives  place  to  a  gelatinous  or  even  a  harder  resistance 
after  a  short  time,  when  the  blood  coagulates.  The  movements  of  the  joint 
are  restricted  when  the  intra-articular  tension  is  very  great.  The  limb  some- 
times assumes  a  position  that  relaxes  the  joint  capsule.  Crowding  the  fluid 
into  one  or  another  part  of  the  joint,  as,  for  instance,  into  the  space  beneath 
the  quadriceps  extensor  by  extending  the  limb  and  apptying  an  elastic  ban- 
dage from  below,  or  by  means  of  the  fingers,  in  the  case  of  the  knee-joint  will 
reveal  fluctuation  in  doubtful  cases.  When  flexion  is  made,  the  fluid  disap- 
pears from  the  region,  the  bandage  being  removed. 

Nomial  Course. — The  blood,  if  it  remains  in  a  fluid  state,  may  become 
resorbed  as  such.  Or,  separation  of  the  fibrin  having  taken  place,  the  fluid 
portion  may  be  resorbed.  It  has  been  shown  that  even  pigment  granules  may 
be  resorbed  in  this  manner.  Their  presence  has  been  demonstrated  in  the 
next  adjacent  lymphatic  glands.  Under  these  circumstances  a  peculiar  crepi- 
tation (snowball  crackling)  is  felt,  due  to  the  presence  of  the  remaining  fibrin. 
Organization  of  the  fibrinous  clots  does  not,  in  all  probability,  take  place,  but 
proliferation  of  the  synovial  membrane  on  the  basis  of  these  may  occur 
which  may  finally  replace  them  and  form  adhesions  within  the  joint  cavity. 
Suppuration  is  rare,  except  in  cases  of  open  wounds.  When  hydrarthrosis 
follows  hemarthrosis,  this  is  probably  due  to  the  accompanying  synovitis. 
Differentiation  of  hydrarthrosis  and  hemarthrosis  is  usually  made  by  the 
history;   in  cases  of  doubt,  exploratory  puncture  will  clear  up  the  diagnosis. 

The  Treatment  of  Injuries  of  the  Joints. — If  these  are  uncomphcated  by 


THE   JOINTS  147 

an  external  wouiul,  oven  though  they  may  be  very  severe  in  character,  simple 
rest  ma}'  suffice  for  conii:)lcte  restoration  of  function.  This  is  well  illustrated 
in  some  forms  of  cUslocation.  Hemorrhage  within  the  joint  requires  no 
treatment,  in  many  instances,  beyond  the  simple  application  of  an  ice-bag  and 
splint.  The  synovial  fluid,  however,  frequently  persists  to  an  extent  requiring 
the  use  of  elastic  compression  (Martin's  elastic  bandage) ;  this  failing, 
tapping  l3y  means  of  a  trocar,  evacuation  of  the  fluid,  and  irrigation  of  the 
joint  by  an  antiseptic  fluid  are  indicated.  Suppuration,  as  indicated  by  urgent 
pains  and  the  occurrence  of  a  high  temperature,  should  be  met  by  incision 
of  the  joint,  antiseptic  irrigation,  and  drainage. 

Wounds  of  Joints. — The  dangerous  character  of  these  demands  the  exer- 
cise of  the  most  rigid  aseptic  and  antiseptic  precautions.  The  irregular  shape 
of  joint  ca"vdties  renders  this  particularly  difficult.  Drainage  will  be  needed, 
as  a  rule,  in  cases  in  which  infection  is  suspected  to  have  occurred. 

When  the  cavity  fails  to  maintain  an  aseptic  condition,  it  may  be  necessary 
to  resect  a  portion  of  the  joint  surfaces,  in  order  to  gain  access  to  it.  This  will 
usually  be  required  in  case  of  wound  of  the  joint  complicated  by  a  fracture. 
The  question  of  total  or  partial  resection  will  depend  on  the  indications 
to  be  fulfilled.  An  improved  functional  result  is  frequentlj^  obtained  by 
this  method  of  treatment,  particularly  in  cases  of  suppuration  due  to 
traumatism. 

In  severe  cases  of  injury  of  a  joint,  primary  or  secondary  amputation  may 
be  demanded.  When  the  joint  alone  is  involved,  however,  resection  will  fre- 
quently suffice.  Injuries  of  large  nerve-trunks  and  vessels,  in  addition  to 
the  wound  of  the  joint,  indicate  primarj'  amputation.  In  suppuration  of  joints, 
whether  resection  or  amputation  is  resorted  to,  any  phlegmonous  processes 
that  have  occurred  along  muscles  and  tendinous  sheaths  must  be  followed  up 
by  free  incisions,  antiseptic  irrigations,  and  efficient  drainage. 

Gunshot  Wounds  of  the  Joints. — In  former  times  gunshot  wounds  of 
the  larger  joints,  such  as  the  knee-joint  and  the  hip-joint,  ranked  among 
the  most  serious  of  this  class  of  injuries.  At  the  present  day,  owing  to  the 
aseptic  care  which  all  wounds  receive,  and  the  use  of  the  armored  or  protected 
projectile,  the  importance  of  these  lesions  has  been  greatlv  reduced.  The 
destructive  effects  of  the  impact  of  the  modern  high-velocity  and  small-caliber 
missile  as  it  strikes  the  spong}'  structure  of  the  articular  extremities  of  long 
bones  without  deviation  from  its  normal  course  or  change  in  its  long  axis, 
even  at  the  shorter  ranges,  are  greatly  minimized,  and  the  resulting  damage 
is  very  limited.  The  wound  inflicted  under  these  circumstances  is  usually  a 
small,  clean-cut  perforation  which  offers  relatively  slight  opportunity  for 
infection.  In  case  of  a  ricochet  shot  with  change  in  the  angle  of  incidence 
from  that  of  a  right  angle  (cross-hits),  particularly  where  deformation  of  the 
bullet  takes  place  (see  page  166),  more  or  less  comminution  of  the  bone  may 
occur  and  a  correspondingly  severe  injury  of  the  joint  result.  In  the  case 
of  the  old-fashioned  large  and  unprotected  ball  the  resistance  met  is  suffi- 
cient to  produce  changes  in  the  shape  of  the  missile,  and  far  more  extensive 
lesions.  The  larger  wounds  inflicted  invite  the  entrance  of  infection  and  the 
extensive  disorganization  of  the  tissues  offers  favorable  opportunity  for  its 
propagation  and  dissemination.  In  addition,  the  low  velocity  often  leads  to 
the  lodgment  of  the  baU. 


148  INJURIES    AND    DISEASES    OF    SEPARATE    TISSUES 

DISLOCATION 

A  more  or  less  permanent  disturbance  of  the  relations  of  joint  surfaces  to 
each  other  constitutes  a  dislocation.  This  may  occur,  as  in  fracture,  from 
either  direct  or  indirect  violence.  I'hysiologic  resistance  to  the  movements 
of  joints  be^'ond  the  normal  limit  resides  in  the  ligamentous  structures.  In 
dislocation  these  are  necessarily  overstretched,  and  torn  to  a  greater  or  lesser 
extent . 

Primary  and  Secondary  Distortion. — An  exaggeration  of  a  normal  move- 
ment, as,  for  instance,  when  hyperextension  at  the  elbow  forces  the  olecranon 
into  the  intercondyloid  fossa  and  removes  the  bones  of  the  forearm  from  their 
relation  to  the  lower  end  of  the  humerus,  constitutes  what  is  known  as 
primary  distortion.  Whether  or  not  a  true  dislocation  occurs  subsequently 
to  this  depends  on  the  further  forcible  movements  to  which  the  joint  is  sub- 
jected, the  character  of  the  dislocation  depending  on  the  direction  of  these  move- 
ments. The  action  of  the  attached  muscles,  together  with  the  position  of  still 
untorn  ligamentous  bands,  constitutes  one  factor  in  determining  the  direc- 
tion of  the  dislocation.  Another  factor  depends  on  the  position  in  which 
the  limb  happens  to  be  placed  when  the  primary  distortion  occurs.  A  third 
relates  to  the  direction  of  the  impinging  force.  With  the  exception  of  the 
first  named,  it  is  frequently  difficult  to  estimate,  in  individual  instances,  the 
prominence  to  be  given  to  each  of  these  factors.  When  the  joint  surfaces  are 
entirely  removed  from  contact  with  each  other,  a  complete  dislocation  or  luxa- 
tion occurs;  when  these  are  still  in  partial  contact,  a  subluxation  is  said  to 
take  place. 

Prognosis. — Simple  dislocations,  properly  reduced,  are  not,  generally  speak- 
ing, important  injuries.  Repair  of  the  torn  capsule  and  of  other  ligamentous 
structures  takes  place  readily.  The  hemorrhage,  as  a  rule,  is  not  alarming. 
In  the  after-treatment,  however,  an  untoward  condition  of  laxity  or  flabbi- 
ness  of  the  joint  may  arise  from  too  early  movements,  which  disturb  the  proper 
repair  of  the  torn  capsule  and  lead  to  a  broad  "splicing"  of  the  rent,  rather 
than  to  immediate  union  of  the  torn  edges.  Recurrence  of  the  dislocation 
may  then  occur  (see  Habitual  Dislocations,  page  150). 

Symptoms  of  Dislocation. — Inspection. — Changes  in  the  contour  and 
size  of  the  extremity  are  at  once  apparent.  Shortening,  except  in  exceptional 
instances  (obturator  dislocations  of  the  femur),  is  present.  An  enforced  posi- 
tion of  the  limb  is  also  observed.  Comparison  with  the  healthy  side  should 
always  be  made.  In  recent  dislocations  some  ecchymotic  discoloration  of 
the  parts  is  present.  Swelling  may  be  a  prominent  feature,  occasionally  to  the 
extent  of  masking  the  symptoms  referable  to  changes  in  contour  and  size. 

Palpation. — The  evidence  derived  from  a  study  of  the  contour  of  the  part 
by  inspection  is  augmented  by  palpating  with  the  fingers.  The  relations  to 
each  other  of  the  bony  prominences  adjacent  to  the  joint  are  thus  made  out. 
In  order  to  assist  in  the  diagnosis  in  case  of  severe  and  recent  hemorrhage  the 
finger  may  be  made  use  of  to  force  the  blood  away  from  the  injured  locality. 

Mensuration. — A  tape-measure  or  other  measure  is  necessary  to  deter- 
mine the  lengthening  or  the  shortening  of  the  entire  extremity,  as  well  as  the 
altered  relations  of  bony  prominences  to  each  other. 

Dislocation  Combined  with  Fracture. — Dislocation  and  fracture  may 
be  combined.     This  may  occur  by  the  breaking  off  of  a  bony  projection  which 


THIO    .lOIXTS  149 

bars  the  progress  of  the  dislocated  bone  (fracture  of  the  coronoid  in  forward 
cUslocation  of  the  humerus  at  the  elbow-joint) ;  by  the  tearing  away  of  the 
bony  insertion  of  an  overstretched  ligamentous  band,  the  bone  giving  way 
before  the  ligament  (Pott's  fracture) ;  and,  finally,  by  the  subsequent  frac- 
ture of  the  previously  dislocated  bone  by  the  same  force.  In  these  cases  the 
symptoms  of  fracture  are  added  to  those  of  dislocation.  In  comparing 
dislocations  with  fractures  it  is  to  be  observed  that  less  functional  disturbance 
results  from  the  former  than  from  the  latter.  The  position  of  the  bone  per- 
mits limited  voluntary  movements  of  the  limb.  In  fracture,  on  the  con- 
trary, the  loss  of  support  of  muscular  attachment  and  the  occurrence  of  ex- 
cessive pain  produce  complete  disability.  On  the  other  hand,  however,  under 
anesthesia  the  utmost  freedom  of  motion  is  observed  in  fracture,  while  this 
is  comparatively  very  hmited  in  dislocation.  Except  in  instances  in  which  a 
dislocated  bone  makes  direct  pressure  on  a  nerve-trunk,  the  pain  in  fracture 
is  greater  than  that  in  dislocation.  Difficulties  in  differentiating  fracture  and 
dislocation  may  occur  when  the  former  exists  in  close  relation  to  a  joint. 
This  is  particularly  true  of  injuries  in  the  neighborhood  of  the  shoulder-joint 
and  hip-joint. 

Treatment  of  Dislocations. — The  immediate  restoration  of  the  nor- 
mal relations  of  the  joint  surfaces  to  each  other,  except  in  cases  complicated 
by  fracture  close  to  the  joint,  is  imperative  in  all  dislocations.  Since  the 
introduction  of  anesthesia,  this  may  be  accomplished  without  the  aid  of  special 
apparatus,  which  in  former  times  was  necessary  to  overcome  muscular  resist- 
ance. In  planning  an  effort  at  reduction  of  a  dislocation  the  attempt  should 
be  made  to  follow  in  a  reverse  order  the  movements  which  led  to  the  disloca- 
tion. The  so-called  secondary  movement  occurring  during  the  luxation  is 
first  to  be  compensated  for  by  a  movement  in  the  opposite  direction,  after  which 
the  primary  distortion  is  to  be  rectified.  These  constitute  the  so-called  ana- 
tomic methods  of  reduction. 

After  reduction  the  enforcement  of  rest  sufficient  to  permit  union  of 
the  torn  ligamentous  structures  will  be  necessary.  The  application  of  an  ice- 
bag  to  lessen  the  pain  and  swelling  will  frequently  be  of  service.  In  simple 
dislocation  a  period  of  fourteen  days  should  elapse  before  even  slight  move- 
ments are  permitted,  retentive  bandages  being  apphed  in  the  meanv\^hile.  In 
dislocations  compHcated  with  fracture,  not  less  than  four  weeks'  immobiliza- 
tion will  suffice.  In  these  cases  too  early  movements  endanger  the  future 
mobihty  of  the  limb  more  than  prolonged  fixation  in  one  position.  While 
complicated  dislocations  are  quite  likely  to  lead  to  some  impairment  of  func- 
tion, simple  dislocations  usually  terminate,  when  properly  treated,  in  com- 
plete restoration  of  former  physiologic  conditions. 

Compound  Dislocations. — Compound  dislocations  are  much  more  rarely 
observed  than  compound  fractures.  The  blunt  articular  extremities  of  the 
bones  do  not  favor  perforation  of  the  overlying  soft  parts  to  the  same  extent 
as  do  the  ends  of  the  fragments  in  fracture.  Exception  to  this  may  be  noted 
in  the  case  of  the  olecranon.  Compound  dislocations  usually  result  from 
machinery  accidents  or  direct  crushing  force.  The  choice  of  treatment  lies 
between  primary  resection  and  reposition  with  antiseptic  treatment.  When  the 
danger  of  infection  is  great,  the  first  course  is  the  safer.  Secondary  resection 
may  be  required,  either  on  account  of  septic  conditions  or  for  the  purpose  of 
improving  the  functional  result,  as  in  the  case  of  the  shoulder-joint. 


150  INJURIES    AND    DISEASES    OF    SEPARATE   TISSUES 

Ancient  Dislocations. — A  failure  on  the  part  of  the  surgeon  to  recognize 
the  presence  of  a  dislocation,  or  a  failure  on  the  part  of  the  patient  to  consult 
proper  authority,  is  responsible  in  the  vast  majority  of  cases  for  that  lapse  of 
time  before  reduction  is  attempted  which  brings  the  injury  within  this  cate- 
gory. Occasionally,  however,  mechanic  or  other  obstacles  defeat  the  best 
directed  efforts  of  the  surgeon  at  reduction.  When  months  elapse,  the  dis- 
location must,  as  a  rule,  be  regarded  as  inveterate,  though  much  will  depend 
on  the  changes  which  in  the  meanwhile  have  occurred  in  and  about  the 
injured  parts.  In  favorable  cases  the  reduction  may  be  effected  in  the  usual 
manner  even  after  some  months.  On  the  other  hand,  restitution  may  be 
impossible.  After  several  weeks  special  care  must  be  exercised  to  avoid 
a  fracture  of  the  bone,  which  may  be  weakened  from  long  disuse,  and  to  avoid 
a  rupture  of  adjacent  vessels  which  are  liable  to  be  somewhat  embedded  in 
the  fibrous  tissue  that  has  developed.  In  the  atheromatous  arteries  of  the 
aged  the  possibility  of  injury  is  increased.  Delay  in  reduction  may  be  neces- 
sitated by  the  existence  of  a  fracture  of  the  shaft  of  the  bone  close  to  the  artic- 
ular extremity.  Here  the  leverage  necessary  for  the  proper  performance  of 
the  manipulation  of  reduction  is  absent. 

The  changes  which  the  joint  surfaces  undergo  in  unreduced  dislocation 
consist  of  a  filling  of  the  inequalities  of  these  surfaces  by  means  of  connective 
tissue  resulting  from  hyperplastic  proliferation  of  the  remains  of  the  torn  cap- 
sule, and  a  disappearance  of  the  cartilage.  In  the  case  of  the  shoulder- joint 
and  hip- joint,  however,  the  pressure  of  the  convex  end  of  the  dislocated  bone 
on  the  periosteum  of  the  bone  against  which  it  rests  leads  to  irritation  of  the 
former  and  a  hyperplastic  proliferation  of  the  same,  with  subsequent  new  for- 
mation of  bone.  In  this  manner  a  substitute  for  the  glenoid  and  acetabular 
cavities  is  formed.  A  deposit  of  fibrous  and  even  hyaline  cartilage  takes 
place  and  a  new  joint  results.  Under  these  circumstances  considerable 
approximation  to  the  normal  movements  may  take  place,  in  which  case  it 
is  not  desirable,  even  if  it  were  possible,  to  reduce  the  dislocation. 

Habitual  Dislocation. — Habitual  dislocation  is  the  tendency  of  a  joint, 
that  has  once  been  dislocated  and  reduced,  to  become  dislocated  again  from 
relatively  slight  causes.  This  occurs  most  frecjuently  in  the  shoulder- joint.  It 
is  due  either  to  an  interruption  of  the  process  of  healing  by  too  early  move- 
ments of  the  joint,  or  to  a  relaxed  condition  resulting  from  an  overstretch- 
ing of  the  capsular  ligament  before  the  newly  formed  tissue  of  repair  has 
acquired  a  normal  resistance.  (Inflammatory  and  the  so-called  congenital 
dislocations  are  confined  almost  exclusively  to  the  hip-joint  and  will  be  dealt 
with  in  the  section  on  diseases  of  that  region.) 

JOINT  INFLAMMATION 

Pathologic  Anatomy  of  Joint  Inflammation.— The  joint  structure 
consists  essentially  of  four  tissues,  the  cartilaginous,  the  bony,  the  synovial, 
and  the  ligamentous.  The  last  two,  though  of  the  connective-tissue  type, 
differ  in  several  important  particulars.  The  synovial  tissue,  from  the  exceed- 
ingly rich  supply  of  vessels,  is  specially  prone  to  inflammatory  conditions, 
while  the  ligamentous  tissue  resembles  the  tendinous  in  its  very  slight  vas- 
cularity, and  hence  is  unimportant  in  inflammatory  processes. 

There  likewise  exist  similar  important  differences  between  the  bony  and 


THE    JOINTS  151 

the  cartilaginous  tissue  of  the  joint  in  relation  to  inflammation.  Chon- 
dritis, or  infiannnation  of  the  cartilage,  in  consecjuence  of  the  slight  vascu- 
larity of  this  tissue,  is  rare  as  a  primary  affection.  Its  participation  in  joint 
disease  is  rather  the  result  of  neighborhood,  its  involvement  being  due  to  an 
advancing  inflammation  of  either  the  adjoining  and  overlying  s\-novial  tissue 
or  the  bony  tissue  beneath.  In  the  former  case  it  is  called  a  chondritis  pan- 
nosa,  in  the  latter,  a  chondritis  granulosa  or  cribrosa,  from  the  sieve-like 
])orforations  that  sometimes  take  place.  Chondritis  in  this  connection  is  clin- 
ically of  but  slight  importance. 

Synovitis  and  Arthritis. — An  inflammation  affecting  the  synovial  mem- 
brane exclusively  is  known  as  synovitis.  When  this  extends  to  the  other  struc- 
tures, or  when  the  process  begins  in  the  bone  or  in  the  whole  joint,  the  lesion 
is  an  arthritis.  Synovitis  is  actite  and  chronic.  Acute  synovitis  is  divided 
into  the  serous,  serofibrinous,  suppurative,  and  catarrhal  varieties.  In 
the  milder  cases  of  the  disease  a  simple  hypersecretion  occurs,  with  perhaps 
a  somewhat  less  fluid  condition  of  the  synovia,  this  constituting  the  simple 
serous  type.  In  more  severe  cases  fibrin  is  added  (serofibrinous) .  In  still  higher 
grades  of  inflammatory  action  emigration  of  white  blood-corpuscles  occurs. 
Except  in  the  milder  types,  acute  suppurative  synovitis  usually  extends  to  the 
articular  strttctures.  Inflammation  of  the  superficial  layer  in  which  a  mucinous 
secretion  takes  place  constitutes  the  catarrhal  variety  (V  o  1  k  m  a  n  n).  Pus 
also  may  be  added  to  the  latter.  In  case  of  wounds  of  joints,  the  cocci 
of  suppuration  may  enter,  with  involvement  of  the  sitrroimding  structures 
(abscess  or  suppuration  of  a  joint). 

Chronic  synovitis  follows  chiefly  two  types:  (1)  Chronic  serous  syno- 
vitis, known  as  hydrarthrosis.  Although  these  cases  were  once  considered 
dropsical,  and  not  inflammatory-,  it  is  now  kno-\-\"n  that  the  fluid  is  the  result 
of  a  low  grade  of  inflammation  of  the  synovial  membrane.  The  membrane 
is  thick  and  boggy  vrith  a  slight  increase  in  vascularity.  The  fluid  is  color- 
less or  light  yellow,  containing  mucus  and  albumin.  It  is  usually  present  in 
large  amount  and  greatly  distends  the  capsule.  (2)  Granulating  or  tuber- 
culous synovitis.  This  is  not  necessarily  an  independent  disease.  It  fre- 
quently develops  from  a  pre-existing  granulating  myelitis  of  the  articular 
extremity  of  the  bone,  reaching  the  synovial  membrane  after  destructive  inva- 
sion of  the  cartilage,  and  thence  the  joint  canity.  During  the  early  stages 
of  tuberculous  synovitis  there  are  two  distinct  types:  in  the  one  the  tubercu- 
lous infection  produces  a  pulpy  degeneration  of  the  entire  sac  with  but  little 
effusion  of  fluid,  the  swelling  being  due  to  the  thick  layer  of  granidating  tissue; 
in  the  other  the  granulating  tissue,  though  present,  is  more  scanty  and  the 
fluid  is  abundant.  These  cases  are  also  kno^^m  as  tuberculous  hydrops 
(S  e  n  n).     Both  may  develop  into  a  complete  tuberculous  arthritis  (vide  infra). 

Hyperplastic  Synovitis. — This  may  either  occur  independently  or  repre- 
sent the  final  stage  of  serous,  suppurative:  or  granulating  synovitis.  The  fringe- 
like processes  found  in  joints  after  inflammatory  conditions  represent  the  pro- 
liferations resulting  from  hyperplastic  sjmo^itis.  Opposing  waUs  of  syno^^al 
pouches,  as  well  as  the  articular  extremities  of  bones  bared  of  cartilage,  msiy 
become  agglutinated,  producing  adhesions  (fibrous  ankylosis).  Not  infre- 
quently lione  is  developed  in  these  comiective-tissue  layers  leading  to  true 
ankylosis. 


152  INJURIES    AND    DISEASES    OF    SEPARATE    TISSUES 

Papillary  Synovitis. — This  is  a  form  of  hyperplastic  synovitis  occurring 
not  infrequently  in  old  age.  The  proliferation  occurs  in  the  shape  of  villi, 
or  flattened  fibrous  indurations.  While  these  are  so  frequently  found  as  to 
be  looked  upon  almost  as  a  normal  condition,  yet,  by  their  increase  in  number 
and  size,  they  may  give  rise  to  symptoms  of  disease,  particularly  in  connec- 
tion with  senile  polypanarthritis  or  arthritis  deformans  (see  below). 
Arthritis,  or  inflammation  of  the  joint  as  a  whole,  may,  like  syno\itis,  be  either 
acute  or  chronic. 

Acute  Septic  Arthritis. — This  lesion,  however  caused,  is  fairly  con- 
stant. The  synovial  fluid  is  increased  in  quantity,  it  soon  becomes  cloudy, 
and  finally  distinctly  purulent.  The  cartilages  become  blue  and  soon  ulcer- 
ate. The  ligaments  are  weakened  and  stretched  and  give  way,  permitting 
the  joint  contents  to  traverse  the  soft  parts  in  all  directions  and  a  displace- 
ment of  the  joint  surfaces  to  occur.  An  acute  osteitis  with  ulceration  or  nec- 
rosis as  a  result,  beginning  at  the  joint  surface,  may  extend  to  the  shaft  of 
the  bones.  The  periarticular  tissues  become  acutely  inflamed  and  abscesses 
appear  in  all  directions;  these  are  often  very  large,  and,  spreacUng  in  the  planes 
of  the  muscles,  may  extend  a  distance  from  the  joint. 

Chronic  Arthritis. — Here  the  lesion  varies  more,  this  variation  depend- 
ing on  the  etiology .  Many  cases  are  cases  of  tuberculous  arthritis.  The  bacilli 
may  be  situated  at  first  in  the  synovial  membrane  and  a  granulating  syno- 
vitis precede  the  complete' arthritis ;  or  a  tuberculous  osteitis,  situated  usually 
at  the  epiphysial  hne,  may  extend  by  the  erosive  action  of  the  granulations 
(caries),  or  by  a  wedge-shaped  infarction  (necrosis)  due  to  the  cutting 
off  of  the  blood  from  a  section  of  bone  by  the  inflammatory  products  result- 
ing from  the  osteitis.  The  escape  of  tuberculous  material  from  the  bone  into  a 
joint  is  followed  by  a  diffuse  tuberculous  arthritis  affecting  the  synovial  mem- 
brane, the  cartilages,  the  hgaments,  and  in  time  the  other  bones.  The  joint 
cavity  is  filled  with  the  degenerated  products  of  the  tuberculous  process 
(so-called  cold  abscess),  but  it  does  not  partake  of  the  character  of  a  septic 
arthritis  until  the  cocci  of  septic  infection  become  added  to  the  tubercle 
bacilU.  This  occurs  when  the  ulcerative  process  reaches  the  surface,  or  it 
may  occur  indirectly  through  the  system. 

Arthritis  Deformans  (Rheumatoid  Arthritis,  etc.). — The  lesion  here  is 
chiefly  a  slow  degeneration,  usually  beginning  in  the  cartilages.  It  is  accom- 
panied by  a  slow  but  abundant  growth  of  cartilage  and  bone,  especially  along 
the  margins.  This  hypertrophy  is  irregular  in  shape  and  has  a  low  grade  of 
vitality.  It  wears  away  when  friction  occurs,  or  breaks  off  and  forms  loose 
bodies  in  the  joint.  The  bones  are  increased  in  size  by  this  irregular  hyper- 
trophy, and  the  projections  may  interfere  mechanically  with  the  move- 
ments of  the  joint.  The  capsule  and  ligaments  undergo  fibrous  degeneration, 
and  contract,  forming  adhesions  that  also  interfere  with  the  motion.  In 
advanced  cases  the  tendons  in  the  neighborhood  may  degenerate  so  that  the 
attachment  to  the  bone  disappears.  Ossification  may  occur  in  the  capsule  and 
tendons.  Suppuration  is  seldom,  if  ever,  present.  The  interior  of  the  joint 
is  usually  dry,  but  in  some  cases  it  contains  a  large  amount  of  fluid. 

Tabetic  Arthropathy  (Charcot's  Joint  Disease).— The  lesion  resembles 
osteoarthritis,  but  the  degeneration  is  more  extensive  and  the  hypertrophy 
much  less.     The  ligaments  become  very  lax,  permitting  much  lateral  move- 


THE    JOINTS  153 

inent,  ami  the  joint  is  swollen,  containing  fluid  and  many  loose  bodies  that 
result  from  the  rapid  deii-eneration. 

Etiology  of  Synovitis. — Acute  synovitis  is  usually  due  to  an  injury. 
A  sprain,  a  contusion,  a  simple  dislocation,  a  fracture  entering  a  joint,  are  the 
more  conunon  causes.  An  aseptic  wound  may  produce  a  serous  synovitis. 
Some  cases  are  nontraumatic  in  origin. 

Synovitis  may  also  result  from  too  prolonged  use  of  a  joint,  particularly 
in  cases  of  relaxation  of  the  ligamentous  apparatus  and  muscular  structures. 
After  prolonged  rest  of  the  part,  as,  for  instance,  fixation  of  the  knee-joint  fol- 
lowing a  fracture  of  the  thigh,  the  first  movements  tend  to  produce  a  serous 
synovitis.  As  septic  synovitis  is  usually  present  in  the  beginning  of  a  septic 
arthritis,  its  etiology  will  be  mentioned  under  that  head. 

Chronic  Serous  Synovitis. — ^This  often  follows  an  incomplete  cure  of  an 
acute  case,  especially  in  a  patient  with  rheumatic  tendencies.  A  displaced 
cartilage,  a  weakened  ligament,  or  a  floating  body  may  by  many  slight  trau- 
matisms result  in  chronic  synovitis.  Some  cases  are  thought  to  be  clue  to 
constitutional  syphilis. 

Granulating  or  Tuberculous  Synovitis. — These  cases  are  due  to  the 
presence  of  the  tubercle  bacillus.  An  injury  by  itself  cannot  produce  this  dis- 
ease, but  an  injury  may  so  lower  the  powers  of  resistance  in  a  joint  that  a  per- 
son who  is  already  suffering  from  an  active  tuberculous  process  or  from  mili- 
ary tuberculosis  (see  page  207),  or  who  afterAvard  becomes  so  infected,  may 
develop  a  tuberculous  synovitis.  Clinically  in  about  one-half  the  cases  a  history 
of  injury  is  obtained.  This  disease  also  frequenth'  occurs  in  children  whose  con- 
dition is  depressed  from  a  preceding  attack  of  one  of  the  exanthemata.  A 
hereditary  tuberculous  history  has  been  thought  by  some  to  predispose  a  child 
to  this  condition  after  a  slight  traumatism  of  the  joint.  The  large  majority 
of  these  cases  occur  in  childhood. 

Acute  Septic  Arthritis. — Suppurative  inflammation  of  joints  arises  from 
penetrating  wounds  of  the  joint,  gunshot  and  othenvise,  compound  fractures, 
and  compound  dislocations.  In  addition,  suppurative  processes  may  be  added 
to  the  forms  of  inflammation  which  are  propagated  from  the  adjoining  peri- 
osteal, medullary,  and  osseous  tissues  (suppurative  osteomyelitis,  granular 
osteomyelitis,  and  periostitis). 

Metastatic  Joint  Inflammation. — In  addition  to  joint  inflammation  of 
local  origin  are  to  be  considered  the  inflammations  in  which  common  pus  cocci 
pass  from  the  blood  into  the  tissues  or,  in  cases  of  pyemia,  on  the  free  surface 
of  the  synovial  membrane  (see  page  184).  likewise  a  primary  tuberculous 
synovitis  must  necessarily  occur  in  the  same  manner,  though  without  doubt 
a  trauma  lessens  the  local  vital  resistance  of  the  part,  and  serves  as  an  excit- 
ing cause. 

Metastatic  inflammation  of  joints  may  likewise  follow  many  of  the  acute 
infectious  diseases,  such  as  variola,  measle's,  typhus,  typhoid,  dysenter}',  etc. 
In  typhoid  fever  but  one  joint,  and  that  the  hip- joint  by  preference,  is  attacked 
by  metastatic  inflammation.  Pathologic  or  inflammatory  dislocation  is  liable 
to  follow. 

Acute  rheumatism  or  polyarthritic  synovitis  (H  u  e  t  e  r) ,  on  account 
of  the  frecjuency  and  importance  of  complications  affecting  internal  organs, 
is  generalh^  treated  of  in  works  on  general  medicine.     It  is  possible  for  pus 


154  INJURIES    AND    DISEASES   OF    SEPARATE    TISSUES 

cocci  to  be  added  to  the  specific  infection  here  present,  though  this  condition 
is  rare.     A  suppurating  joint  may  follow. 

Arthritis  Uratica. — The  condition  knowTi  as  the  uric  acid  diathesis  gives 
rise  to  a  form  of  arthritis.  The  joints  of  the  toes  are  particularly  liable  to  this 
affection  (podagra).  This,  like  the  preceding,  is  described  in  works  on  general 
medicine. 

Gonorrheal  Arthritis. — It  occasionally  happens  in  the  course  of  acute 
gonorrheal  urethritis,  especially  in  the  later  weeks,  that  a  metastatic  arthritis 
due  to  the  emigration  of  the  specific  organism  of  the  disease,  the  gonococcus 
of  Neisser,  occurs  in  a  joint.  The  knee-joint  is  the  part  most  frequently 
attacked,  though  any  articulation  may  become  the  seat  of  the  infection. 
This  disease  is  occasionally,  though  improperly,  called  "gonorrheal  rheu- 
matism." It  follows  the  course  of  a  septic  arthritis,  but  is  usually  of  a  milder 
tj^pe  than  the  ordinarj^  pus-joint. 

Tuberculous  arthritis  arises  from  a  tuberculous  synovitis  or  from  a  tuber- 
culous osteitis,  usually  at  the  epiphysial  line.  The  etiology  of  osteoarthritis 
is  still  unsettled.  Rheumatism  and  gout  perhaps  predispose  to  this  condition. 
There  is  often  a  histor}^  of  heredity.  In  a  predisposed  person  it  often  develops 
after  traumatism.  The  view  more  recently  advocated  places  its  cause  in  a 
degeneration  of  the  trophic  nerv^es.  It  is  more  prevalent  among  those  whom 
poverty  and  exposure  have  weakened. 

Tabetic  Inflammation. — C  h  a  r  c  o  t ,  in  1868,  pointed  out  the  rela- 
tive frequency  of  joint  affections  in  patients  suffering  from  tabes.  He  asserted 
that  they  appeared  by  preference  in  the  earlier  stages  of  the  disease. 
Rotter  and  K  r  e  d  e  1 ,  however,  in  studying  the  statistics  of  the  affec- 
tion, showed  that  in  the  majority  of  severe  cases  the  advanced  or  ataxic 
stage  of  the  disease  was  chosen.  It  was  therefore  suggested  by  V  o  1  k  - 
m  a  n  n  that  these  arthropathies  were  really  due  to  traumatic  influences 
on  joint  structures  deprived  of  proper  nerve-supply  and  hence  the  subject 
of  nutritive  disturbances  and  atrophic  changes. 

Clinical  History  of  Serous  and  Suppurative  Synovitis. — When 
the  joint  is  at  rest,  neither  pain  nor  fever  is  a  pronounced  symptom  in  serous 
synovitis,  unless  a  rheumatic  element  is  also  present.  Motion  is  restricted 
by  the  presence  of  the  effusion  and  by  the  pain  caused  by  attempted  move- 
ments. Local  heat  is  present  but  not  marked,  and  the  patient  holds  the  joint  in 
a  partially  flexed  position.     There  are  no  pronounced  constitutional  symptoms. 

Suppurative  Synovitis. — Considerable  pain  and  fever  are  characteristic 
symptoms  of  joint  suppuration.  General  septic  infection  rapidly  follows 
this  condition,  marked  by  irregular  chills  and  the  general  symptoms  of  fever; 
the  temperature  varies  from  102°  F.  to  105°  F.  With  the  involvement  of  sur- 
rounding structures  and  the  rupture  of  the  capsular  ligament,  the  arthritic 
inflammation  lessens  in  severity.  The  fever  may  abate  and  granulations  spring 
up  in  the  joint  cavity.  The  cicatricial  formations  which  follow  may  obhterate 
the  joint,  and  recovery  finally  take  place,  with  loss  of  function  of  the  articu- 
lation. In  large  and  complicated  joints,  if  free  exit  is  not  given  to  the  pus 
and  antiseptic  treatment  instituted,  the  products  of  suppuration  are  retained 
and  absorption  of  toxemic  infectious  agents,  or  prolonged  suppuration  with 
new  foci  constant^  developing,  leading  to  amyloid  degeneration  of  abdominal 
organs,  may  destroy  the  patient. 


TflE   JOINTS  155 

Metastatic  Suppurative  Synovitis. — 'lliis  may  be  accompanied  by  but 
slight  local  symptoms,  'i'he  general  symptoms  are  those  of  the  original  con- 
dition from  which  the  infection  was  derived.  It  is  sometimes  found  at  the 
autopsy  when  no  suspicion  of  its  presence  existed  during  life.  At  other  times 
the  joint  condition  is  the  chief  lesion  of  a  pyemia  (see  page  184). 

Clinical  History  of  Tuberculous  Joint  Inflammation.— The  course 
of  a  favorable  case  of  tuberculous  joint  disease,  when  treated  mechanically, 
is  from  one  to  three  years.  If  this  treatment  is  efficient  and  the  general  health 
improved  by  the  administration  of  tonics,  the  process  may  stop  at  any  point 
and  repair  be  instituted  with  a  more  or  less  perfect  recovery  of  motion,  the 
latter  depending  on  the  extent  of  the  process.  But  the  process  may  go  on 
in  two  ways:  (1)  In  those  instances  in  which  tuberculous  synovitis  does  not 
tend  to  secondary  suppuration  the  disease  passes  by  infection  into  all  the 
adjacent  tissues.  The  resulting  granulating  inflammation  produces  fusion  of  the 
ligaments,  cartilage,  and  bones  of  the  joints,  as  well  as  of  neighboring  bursae, 
sheaths  of  tendons,  and  the  tendons  themselves.  The  skin  itself  finally  becomes 
involved,  and,  with  the  occurrence  of  suppuration  and  ulceration,  fistulous 
canals  lead  to  the  interior  of  the  diseased  joint.  Spontaneous  closure  of  these 
is  very  rare.  As  one  closes,  another  opens,  until  death  comes  to  the  patient's 
relief.  This  may  take  place  from  general  miliary  tuberculosis,  particularly  of 
the  lungs,  or  by  tuberculous  enteritis  or  meningitis.  Amyloid  degeneration 
of  the  spleen,  liver,  and  kidneys  likewise  leads  to  a  fatal  result.  Enlargement 
of  the  liver  and  spleen  and  albuminuria  from  the  kidney  involvement  char- 
acterize this  condition.  Amyloid  degeneration  of  the  mucous  membrane  of 
the  bowels  leads  to  chronic  and  intractable  diarrhea.  This  may  occur  simul- 
taneously with  general  tuberculosis.  Septicemia  and  pyemia  may  occur  at 
any  time  during  the  course  of  the  disease.  (2)  The  joint  may  take  on  a  septic 
process  before  any  direct  opening  ulcerates  through,  and  the  patient  suffers 
from  the  mixed  infection.  The  case  is  then  clinically  an  acute  septic  arthritis 
and  should  be  so  treated.  The  first  method,  however,  is  the  usual  one  followed 
by  tuberculous  joints  when  they  take  an  unfavorable  course. 

The  simplest  form  of  hyperplastic  synovitis  is  that  in  which  a  thickening 
of  the  reflection  of  the  synovial  membrane  over  the  intra-articular  cartilages 
occurs.  From  the  resemblance  of  this  to  the  thickening  of  the  conjunctiva 
over  the  cornea,  called  pannus,  this  variety  is  called  synovitis  pannosa 
(Hueter).  The  only  danger  to  be  anticipated  from  pannous  synovitis 
is  the  occurrence  of  adhesions  between  two  opposing  surfaces,  leading  to  sub- 
sequent limitation  of  movements  of  the  joint. 

Hyperplastic  Papillary  Synovitis. — This  form  is  so  intimately  associated 
with  villous  thickening  of  the  rest  of  the  structure  of  the  joint  that  it  is  diffi- 
cult to  differentiate  it  chnically.  It  is  very  slow  in  its  course,  extensive  fibrous 
induration  of  the  capsule  and  thickening  of  the  bony  structure  occur,  and, 
in  the  case  of  superficially  situated  joints,  considerable  deformity  may  result. 
On  this  account  it  has  been  called  arthritis  deformans.  This  name,  however, 
necessarily  implies  a  deformity,  which  does  not  always  occur.  From  the  fact 
that  all  of  the  component  parts  of  the  joint  are  more  or  less  involved,  the  term 
hyperplastic  polypanarthritis  has  been  suggested  (Hueter).  In  the 
majority  of  cases  a  single  joint,  or  a  group  of  joints,  as  the  fingers,  is  attacked. 
Pain  on  movement,  cracking  or  grating  sensations,  and,  finally,  restriction 
of  the  movements  of  the  involved  parts  are  the  prominent  symptoms. 


156  INJURIES   AND    DISEASES   OF   SEPARATE   TISSUES 

General  Diagnosis  of  Inflammation  of  Joints. — Inspection. — Usualh- 
swelling  is  present.  Often  this  is  made  more  pronounced  by  an  atrophy 
of  the  muscles  over  the  adjoining  bones,  as,  for  example,  the  spindle  shape 
in  a  case  of  tuberculosis  of  the  knee  caused  by  the  swollen  joint  and  shrunken 
thigh  and  calf.  In  other  cases,  however,  the  atrophy  of  the  muscles  directly 
over  the  joint  may  compensate  for  the  inflammatory  swelling.  Under  these 
circumstances  the  diseased  joint  may  be  smaller  in  circumference  than  the 
corresponding  healthy  joint.  Only  exceptionally  the  inflamed  joints  appear 
red,  ^'iz.,  in  the  acute  septic  cases,  and  then  only  when  the  overlying 
tissues  are  involved.  Many  chronic  cases  appear  white  from  the  deficient 
circulation  in  the  skin  that  is  stretched  by  the  swelling.  By  inspection 
we  note  also  the  position.  An  inflamed  joint  is  held  at  the  angle 
that  will  produce  the  least  amount  of  tension  in  the  capsule.  Usually  this 
is  a  slightl}-^  flexed  position. 

Palpation. — The  presence  or  absence  of  fluctuation,  as  well  as  of  edema- 
tous conditions  of  the  surrounding  parts  in  the  beginning  of  the  disease,  and 
of  fibrous  indurations  later,  is  to  be  determined  by  palpation.  The  presence 
of  softening  in  the  midst  of  an  indurated  surface  is  an  evidence  either  of  a  more 
rapid  advancement  of  a  granulating  inflammation  or  of  the  occurrence  of  ab- 
scess. Friction  sensations  are  conveyed  to  the  hand  by  palpation,  which  may 
be  due  to  the  presence  of  foi'eign  bodies,  deposits  of  fibrin,  loosened  portions 
of  necrotic  cartilage,  loosened  epiphyses  from  inflammatory  action,  the  ftic- 
tion  of  the  bony  joint  surfaces  deprived  of  their  cartilaginous  coverings,  etc. 
These  -uiU  var\^  in  quality  and  other  characteristics  according  to  the  causes 
producing  them.  Slight  limitations  of  motion  are  discoverable  only  by  care- 
ful comparison  with  the  sound  side  and  by  the  gentle  movement  of  the  joint 
through  the  full  extent  of  normal  range.  This  limitation  is  often  the  first 
symptom  of  a  chronic  joint  affection.  "When,  as  is  often  the  case,  it  is  due  to 
muscular  spasm,  it  disappears  under  an  anesthetic.  TMiile  normal  move- 
ments may  be  restricted,  abnormal  movements,  particularly  in  joints  in  which 
lateral  movements  are  not  possible  in  healthy  conditions,  may  be  present,  from 
relaxation  or  destruction  of  othenvise  limiting  ligamentous  structures. 

Local  elevation  of  temperature  is  also  discoverable  by  palpation,  in  acute 
inflammations,  but  is  absent  in  those  f  oho  wing  a  chronic  course.  Thermo- 
metric  observations  are  best  carried  on  by  the  aid  of  the  clinical  thermometer. 
Evening  rise  of  the  general  temperature  inchcates  either  a  suppurative  process 
or  a  general  infection,  tuberculous  or  otherwise. 

Prognosis  of  Inflammation  of  Joints. — This  relates  (1)  to  the  func- 
tion of  the  joint:    (2)  to  the  general  health  and  life  of  the  patient. 

Acute  serous  synovitis  under  proper  treatment  is  usually  cured,  leaving 
a  perfect  joint.  If  improperly  treated,  or  where  the  cause  is  often  repeated, 
it  may  reach  the  chronic  stage.  In  predisposed  or  weakly  persons  it  may  be 
the  foundation  of  a  tuberculous  synovitis.  Chronic  serous  synovitis  causes 
a  relaxation  of  the  ligaments  and  a  weakened  joint. 

Acute  septic  synovitis,  if  energeticafly  treated  by  proper  means,  may  give 
a  fairly  good  functional  result,  though  probably  never  a  perfect  one.  Usuafly, 
however,"  a  fibrous  or  osseous  ankylosis  follows,  if.  as  frequently  occurs,  a  septic 
arthritis  develops. 

High  grades  of  septic  inflammation  in  a  large  joint  may  be  followed  Ijy  a 


THK    JOINTS  157 

fatal  result.  Even  a  finger-joint,  the  seat  of  suppurative  inflammation,  may 
become  a  source  of  danger,  tlie  supjniration  advancing  in  the  synovial  sheath 
of  a  tendon.  In  acute  sui^purati\-e  inflammation  death  takes  place  from  sep- 
tic and  pyemic  complications. 

Early  cases  of  tuberculous  synovitis,  occurring  in  individuals  who.se 
(general  health  is  good  and  in  whom  the  amount  of  tuberculous  infection  is 
kiidit.  often  yield  a  surprisingly  good  functional  result  after  careful  and 
prolonged  mechanic  treatment.  In  most  cases,  howe^•er,  there  is  more  or  less 
restricted  motion  and  a  shortening  of  the  limb.  These  cases  may  re.sult 
fatalh-  from  exhaustion,  acute  general  tuberculosis,  acute  phthisis,  or  tuber- 
culous meningitis.  Amyloid  degeneration  of  the  abdominal  organs  may 
supervene. 

The  prognosis  in  osteoarthritis  is  in  the  direction  of  slowly  developmg 
increase  of  all  symptoms;  these  can  be  relieved  and  arrested,  but  seldom,  if 
ever,  entirelv  cured.     Total  disability  results  in  extreme  cases. 

Treatment  of  Inflammation  of  Joints.— Acute  synovitis  reciuires 
rest.  This  must  be  complete.  The  apparatus  appHed  to  effect  this  must 
itself  not  give  pain.  (For  the  various  methods  for  the  different  joints  see 
Regional  Surgery.)  The  coil  with  ice-water,  or  the  ice-bag,  is  of  great  value. 
An  average  case  requires  but  little  general  treatment  except  a  laxative  and 
perhaps  a"  sedative.  Patients  with  a  rheumatic  tendency,  although  the  joint 
trouble  is  traumatic,  are  often  relieved  by  the  salicylates. 

Septic  synovitis  requires  free  incisions  and  complete  drainage  with  anti- 
septic irrigations,  in  addition  to  proper  splints. 

In  chronic  serous  synovitis  marked  by  persistent  effusion,  moderate 
compression  and  the  actual  cautery  may  be  tried  before  puncture  and  irriga- 
tion of  the  joint  canity.  ^Miile  in  this  class  of  cases,  as  well  as  in  para- 
synovitis, much  benefit  may  be  derived  from  compression  and  massage,  m 
granulating  svnovitis  their  employment  is  not  followed,  as  a  rule,  by  the  same 
favorable  results.  Compression  is  best  applied  by  means  of  the  ''circular 
bandage"  so  called,  as  used  for  varicose  vems. 

Treatment  of  Tuberculous  Synovitis.— In  this  form  of  uiflammation 
the  microorganisms  which  produce  the  local  disturbances  invade  the  tissues 
from  the  blood.  In  this  sense,  therefore,  it  is  a  local  manifestation  of  a  general 
infection,  and  requires,  as  weU  as  local  treatment,  a  regard  for  the  patient's 
general  health.  This  wiil  include  nitrogenous  food  in  amj^le  quantities,  pure 
air.  and  the  best  hygienic  surrotmdmgs. 

The  employment  of  such  local  measures  as  bhstering  and  the  use  of 
the  thermocauteix  m  the  treatment  of  tuberculous  s^movitis  has  not  yielded 
ver\'  satisfactory^'  results.  Fixation  and  cauterization,  when  combined  ^^ith 
a  vigorous  effort  to  restore  the  general  health,  is  occasionally  followed  by 
improvement.  Intra-articular  mecUcation,  consisting  of  the  introduction,  by 
means  of  a  trocar  and  an  injecting  syringe,  of  Peruvian  balsam  or  of  a 
10  per  cent  emulsion  of  iodoform  m  glycerin  (B  ru  ns),  is  a  far  more  rational 
procedure  and  worthy  of  more  extended  trial. 

AAlien  the  disease'  has  advanced  to  the  stage  of  suppuration,  the  most  rad- 
ical measures  are  necessary  for  its  relief.  These  consist  in  resecting  the 
joint  surfaces,  and  scooping  out  T^ith  Y  o  1  k  m  a  n  n  '  s  sharp  spoon, 
or  thorouglily  cauterizing  by  means  of  the  themiocauters-  all  suspicious  foci 


158  IXJURIES    AXD    DISEASES    OF   SEPARATE    TISSUES 

(for  Evidement.  see  page  369).  The  entire  synovial  membrane  is  to  be  dis- 
sected away  and  all  fistulous  tracts  are  to  be  curetted  thoroughly  or  removed. 
Simple  scraping  and  cutting  away  of  the  diseased  S3'novial  membrane  (Era- 
sion,  see  page  372),  -u-ith  or  without  partial  resection  (Arthrectomy,  see  page 
372),  is  a  measure  not  so  well  calculated  to  achieve  the  best  results  as  typic 
resection  and  evidement.  Reinfection,  as  evinced  by  the  failure  of  the  parts 
to  heal  promptly,  demands  a  repeated  application  of  the  sharp  spoon  and  ther- 
mocautery. 

Wide]}-  vaning  opinions  exist  as  to  the  benefit  to  be  derived  from  the 
mechanic  treatment  of  joint  disease.  While  the  orthopedic  surgeon  is 
inclined  to  rely  almost  exclusively  on  this,  the  general  surgeon,  less  familiar 
with  complicated  apparatus,  and  more  at  home  in  the  operative  field  of  work, 
advises  and  employs  methods  of  a  more  radical  nature.  It  is  probably  true 
that  mechanic  treatment  is  of  the  greatest  service  in  the  ver\"  beginning  of 
joint  disease,  particularly  in  that  of  the  hip-joint,  though  in  the  later  stages 
of  tuberculous  disease  of  joints  its  effect  has  been  very  greatly  overestimated. 
Mechanic  treatment,  to  be  most  effective,  must  fulfil  the  follo^^■ing  three 
indications:  (1)  fixation;  (2)  extension;  (3)  protection.  By  the  latter  is 
meant  preventing  all  traumatism  or  weight  from  affecting  the  inflamed 
joint.  Unless  these  three  indications  are  provided  for,  rest  is  not  perfect, 
and  but  little  can  be  accomplished  mechanically  in  the  way  of  arresting  or 
curing  a  tuberculous  process.  Though  these  methods  of  treatment  are  in 
a  great  measure  s^Tiiptomatic,  yet  they  serene  a  ver\'  important  purpose,  both 
locally  and  generally,  and  can  be  carried  on  while  intra-articular  injections 
are  being  practised.  Fixation  may  possibly  assist  in  preventing  dissemination 
of  the  infection,  which  is  more  or  less  favored  by  movements  of  the  joint. 

Another  object  of  mechanic  treatment  is  the  correction  of  malposition 
of  the  limb.  This  is  effected  by  converting  in  a  gradual  manner,  the  flexed 
into  the  extended  position  by  means  of  traction  by  weight  and  pulley  exten- 
sion, combined  with  apparatus  which  utilizes  the  weight  of  the  limb  itself  to 
accomplish  the  object  (for  special  apparatus,  see  Regional  Surgen,'). 

The  mechanic  treatment  will  include  local  compression  and  massage. 
These  are  to  be  employed  only  after  the  acute  symptoms  haA'e  subsided ;  they 
are  more  or  less  useful  in  promoting  restoration  of  function,  but  they  take  no 
part  in  the  cure  of  the  disease  itself. 

Osteoarthritis. — ^The  treatment  in  tliis  case  is  an  exception  to  the 
general  nde  that  joint  diseases  rec{uire  immobilization.  Except  during  acute 
exacerbations  of  the  process,  active  and  passive  motions  with  massage,  etc. 
should  be  advised.  Steaming  the  joint  daily  in  hot  flannels  relieves  much  of 
the  pain.  Blisters  and  the  actual  cauter\'  are  useful.  In  early  cases  iodid  of 
iron  and  sometimes  arsenic  is  indicated.  Hygiene  and  an  out-of-door  life 
are  of  great  importance  in  arresting  the  progress  of  the  disease.  An  annual 
"cure"  at  one  of  the  alkaline  or  sulfur  springs  may  temporarily  improve  a 
case. 

Periarticular  Inflammations. — It  may  happen  that  an  inflammation, 
usually  suppurative  in  character,  occurs  in  the  tissues  surrounding  a  joint. 
A  contusion  resulting  in  a  collection  of  effused  blood  outside  the  ligaments 
becomes  infected  through  an  abrasion,  or  through  the  blood-channels  from  a 
distant  focus,  and  a  condition  arises  which,  in  its  local  aspects  and  constitu- 


1  ">Q 
THE    JOINTS  ^'^^ 


tion-il  .vmptoms.  closelv  resembles  a  septic  arthritis.  Tenderness  and  pam 
on  motion,  loss  of  function,  and  general  sepsis  are  present.  It  is  not  eas>  to 
dia-nose  some  of  these  periarticular  inflammations.  It  may  be  noted  that 
the° characteristic  position  assumed  by  the  joint  in  question,  when  it  is  the 
he  of  a  septic  arthritis,  is  absent.  This  is  clue  to  the  fact  that  mtra-articu  ar 
iension  is  not  present  to  cause  the  position.  The  onset  of  these  cases  is  also 
less  abrupt,  as  the  absorbing  surface  is  less  extensive. 

The  treatment  of  these  cases  is  incision  and  dramage :  tliLS  should  be  prompt, 
so  as  to  protect  the  adjacent  joint.  The  prognosis  for  a  full  recovery-  of  function 
is  excellent. 

CONTRACTURE  AND  ANKYLOSIS 
Contracture.— A  restriction  of  the  normal  range  of  motion  in  a  joint  con- 
stitutes a  contracture. 

Cicatricial  contractures  arise  from  the  action  of  more  or  less  extensive 
cicatrices  these  usuallv  resulting  from  bums  and  scalds  and  situated  on  the 
flexor  aspect  of  the  limb.  The  skin  alone,  or  the  skin  and  the  fascia  and 
muscles  in  addition,  mav  be  involved  in  the  cicatrix.  The  joint  is  not  neces- 
sarily involved,  though  secondar^'  changes,  from  pressure  and  position,  may 
take  i^lace  in  the  articulation.  .   .     . 

Myogenous  and  tendogenous  contractures  are  consequent  on  mj lines 
and  inflammation  of  the  muscular  apparatus.  The  muscles  may  be  prevented 
from  moving  independentlv  of  one  another,  or  they  may  be  shortened  from 
nutritive  disturbances  foUo^^ing  rupture,  or  from  cicatricial  deposit  toUow- 
ino-  the  accident,  as.  for  instance,  the  wiy  neck  after  a  breech  dehyer^'. 
FamiUar  examples  of  tendogenous  contracture  are  found  m  the  contracted  fin- 
gers so  commonlv  obser^-ed  to  foHow  phlegmonous  iiiflanmiation  of  the  pahn  ot 
the  hand  and  invohing  the  sheaths  of  the  flexor  tendons. 

Neurogenous  contracture  develops  after  paralysis  ot  the  motor  nen'es, 
the  mu-cles  undersoing  nutritive  shortening.  Pes  paralyticus  is  the  most 
important  of  the  contractures  in  this  group.  Here  the  muscles  that  are  para- 
Ivzed  suffer  from  the  continual  tension  to  wliich  they  are  subjected,  wMe  the 
muscles  that  stiU  receive  a  proper  nen-e-supply  become  permanently  shortened 
bv  a  constant  approximation  of  their  points  of  origin  and  msertion.  from  ab- 
sence of  an  opposing  force.  Paralysis  of  a  single  nen-e  trunk  may  comphcate 
the  conditions.     Neurogenous  contractures  of  the  hand  and  fingers  are  usually 

distinctlv  defined.  .    ^     .  ■  ■      •      ^i  ^  ;^;r.+ 

Arthrogenous  Contractures.-This  group  finds  its  ongm  m  the  jomt 
apparatus  itself,  and  is  of  the  greatest  importance  in  its  bearmg.  especiaUy  on 
the  prognosis  of  arthritic  inflammation.  Etiologically.  arthrogenous  contrac- 
tures mav  be  divided  into  those  which  are  congenital  and  those  which  are 
inflammator^^  The  first  named  appear  as  contractures  of  the  foot  (<;ongenital 
clubfoot)-  less  frequentlv  as  contractures  of  the  carpus  (congemtal  clubhand); 
finaUy,  still  more  rarely' as  congenital  knock-knee,  or  genu  valgum  (see  these 

deformities).  .  .  ,         _^i 

\moncr  the  most  important  seciuels  of  arthritis  are  the  arthrogenous 
contractures  Thev  form  the  great  majority  of  cases  of  tins  class  coimng 
under  obser^-ation;  hence   their  hnportance.     ^Mren    due   to   the   presence 


160  INJURIES   AXD    DISEASES    OF   SEPARATE   TISSUES 

of  an  acute  synovial  inflammation,  on  the  disappearance  of  this  in  most 
instances  they  vanish  in  whole  or  in  part.  In  other  cases  some  disturbance 
of  function,  more  or  less  permanent,  results.  The  contracture  due  to  tension 
of  the  joint  capsule  in  larjje  effusions  within  the  joint  is  likewise,  as  a  rule,  onh' 
temporary.  Granulating  inflammation  within  the  capsule,  however,  inter- 
feres greatly  with  the  movements  of  the  joint.  Cicatricial  contracture  of  the 
capsule  prevents  it  from  following  the  joint  movements.  In  cases  of  osteo- 
arthritis the  swelling  of  the  bony  substance  likewise  restricts  the  movements. 
Proliferation  of  the  cartilaginous  or  synovial  tissue  will  offer  mechanic  ob- 
stacles as  well.  The  indurations  remaining  in  the  subsynovial  connective  tis- 
sue after  suppurative  inflanunation  of  the  synovial  membrane  interfere  more 
or  less  "^'ith  the  mobility  of  the  joint. 

Fracture  in  the  neighborhood  of  a  joint  or  communicating  with  it, 
by  an  abundant  formation  of  callus  may  restrict  its  movements  very  seriously. 
In  the  case  of  the  elbow-joint,  particularly,  the  deposit  of  callus  in  the  capsule 
(the  so-called  ossification  of  the  capsule)  is  of  great  importance.  Projecting 
masses  of  callus  having  their  origin  in  the  torn  periosteum,  or  in  displaced 
centers  of  ossification  in  children,  also  hinder  the  mo^'ements  of  the  joint. 
Finalh',  hyperplastic  synovial  inflammation,  giving  rise  either  to  vascular 
processes  in  two  or  more  portions  of  the  joint  which  become  adherent,  or  to 
direct  adhesion  of  two  opposing  surfaces,  as  in  pannous  synovitis,  may  seriously 
cripple  the  usefulness  of  the  joint. 

Ankylosis. — This  term  means  literally  an  angular,  bent,  or  crooked  joint. 
In  this  sense  it  may  be  applied  to  most  contractures.  It  is  properly  applied, 
however,  to  joints  w^hich  are  incapable  of  movements,  whether  in  the  flexed 
or  in  the  extended  position. 

False  Ankylosis. — This  term  is  applied  to  those  cases  in  which  joints, 
apparentl}'  immo^'ably  fixed,  can  be  moved  throughout  the  normal  range, 
under  an  anesthetic.  Muscular  spasm  of  these  cases  is  the  cause  of  the 
rigidity. 

True  Ankylosis. — This  signifies  a  solid  attachment  of  two  articulating 
surfaces.  Three  varieties  are  distinguished:  (1)  the  fibrous;  (2)  the  cartila- 
ginous;  (3)  the  osseous. 

Fibrous  Ankylosis. — In  this  variety  movements  may  be  impossible^  or 
a  certain  amount  of  mobility  may  be  present.  The  extent  of  motion  will 
depend  on  the  firmness  of  the  tissue  connecting  the  joint  surfaces.  This  tis- 
sue is  derived  from  either  the  synovial  membrane  or  the  connective  tissue  of 
the  medullar}^  structure.  In  the  first  case  it  occurs  in  the  shape  of  smooth 
projections  from  the  border  of  the  capsular  insertion  on  the  joint  surfaces. 
Two  layers  of  connective  tissue,  therefore,  are  present,  each  progressing  over 
its  corresponding  articular  surface.  These  may  unite  directly,  the  underlying 
cartilages  becoming  attached  to  each  other  through  the  medium  of  these  layers 
of  newly  formed  tissue.  In  cases  in  which  the  cartilage  has  been  destroyed 
in  consequence  of  an  advancing  granulating  myelitis,  the  bony  tissues  them- 
selves are  connected  by  means  of  this  connective  tissue,  which,  soft  at  first, 
may,  in  consequence  of  cicatricial  contraction,  become  firm  and  fibrous. 

Cartilaginous  Ankylosis. — The  fibrous  form  may  become  converted  into 
the  cartilaginous  by  the  development  of  cartilage  in  the  connective  tissue  cover- 
ing  the   still  intact  joint   cartilages.      This  variety  may  occur  after  granu- 


THE    JOINTS  161 

latiiiii;  synovitis  and  snppurative  conditions;  it  is  most  frequently  observed, 
}u>\\ (^cr,  after  fractures  communicating  with  the  joint. 

Osseous  Ankylosis. — Bony  ankylosis  may  develop  after  either  the  fibrous 
or  iho  cartilaginous  form.  In  the  former  case  a  cicatricial  development  of 
connective  tissue  occurs,  the  cartilage  being  destroyed  in  whole  or  in  part  by  a 
granulating  myelitis.  This  cicatricial  tissue  contracts  and  gradually  ossifies 
in  \-ery  much  the  same  manner  as  callus  in  union  of  fractures.  In  the  latter 
case  tlic  cartilaginous  strip,  which  still  remains  intact,  ossifies. 

It  is  therefore  evident  that  ankylosis  appears  first  as  fibrous;  this  may 
subsequently  be  converted  into  the  cartilaginous  and  thence  into  the  osseous, 
or  may  pass  directly  into  the  osseous.  In  either  case  the  transformation  is 
necessarily  very  slow,  occupying  years  for  its  completion. 

Treatment  of  Contracture  and  Ankylosis. — While  every  effort  should 
be  made  to  preserve  as  far  as  possible  the  full  range  of  movement  in  the  limb, 
it  will  occasionally  happen  that,  in  spite  of  every  precaution,  ankylosis  occurs. 
Under  these  circumstances  it  is  imperative  that  the  position  of  the  joint  should 
be  such  as  to  insure  the  greatest  usefulness  to  the  limb.  In  the  case  of  the 
knee,  this  will  be  in  an  almost  extended  position,  and  in  the  elbow,  at  a  right 
angle. 

The  treatment  of  both  contracture  and  ankylosis  may  be  divided  into  (1) 
manual  passive  movements ;  (2)  manual  correction  under  an  anesthetic ;  (.3)  cor- 
rection by  weight  and  pulley  extension;  (4)  correction  by  instrumental  means 
(pressure  and  traction) ;  (.5)  tenotomy ;  (6)  resection ;  (7)  osteotomy ;  (8) 
amputation. 

Manual  passive  movements  should  be  first  attempted.  Slight  contrac- 
ture of  short  duration  will  frequently  yield  to  these.  Passive  movements 
promise  success  when  an  increase  in  the  range  of  motion  is  evident  on  measure- 
ment. When  night  pains  follow  the  employment  of  passive  movements,  no 
improvement  is  to  be  expected,  as  a  hyperplastic  inflammation  is  being  set  up 
which  tends  to  increase  still  farther  the  rigidity.  They  must  then  be  employed 
less  vigorously  or  give  place  to  other  methods.  When  they  have  failed,  man- 
ual correction  under  an  anesthetic  may  be  resorted  to,  in  which  consid- 
erable tearing  of  the  tissues  results.  This  forced  correction  should  not  be 
applied  to  tuberculous  joints  until  all  active  processes  have  ceased. 
Even  then  it  may  arouse  a  latent  focus  to  renewed  activity.  This  may  or 
may  not  precede  the  third  method,  that  of  correction  by  weight  and  pulley 
extension.  The  latter  is  usually  resorted  to  when  the  deformity  results 
from  excessive  irritability  of  the  muscular  structures  due  to  an  active  inflamma- 
tory condition. 

Correction  by  instrmnental  means  consists  in  the  adaptation  of  appara- 
tus which  accomplish  the  object  by  gradual  pressure  and  traction,  such,  for 
instance,  as  in  congenital  clubfoot  and  knock-knee  (see  these  deformities). 

Tenotomy  or  myotomy  may  be  substituted  for  the  above  in  cases  in  which 
the  contracture  is  of  tendinous  or. muscular  origin.  It  is  employed  also  in 
cases  in  which  it  is  necessary  to  remove  resistance  of  tendons  in  order  to  per- 
mit other  methods  of  treatment,  e.  g.,  extension  by  traction  in  ankylosis  of 
the  knee  after  section  of  the  hamstring  tendons. 

Resection  of  the  diseased  joint,  or  of  such  portions  thereof  as  are  necessary 
for  the  correction  of  the  deformity,  constitutes  a  very  effective  method  of 
12 


162  INJURIES    AND    DISEASES    OF    SEPARATE    TISSUES 

treatment.  It  is  particularly  useful  in  cases  in  which  a  newly  formed  joint 
may  develop  (see  Resection  of  Wrist-joint,  Elbow-joint,  Shoulder- joint,  etc.). 

Osteotomy. — Osteotomy  is  specially  applicable  to  the  hip-joint  and  the 
knee-joint.  It  is  performed  by  saw  or  chisel,  applied  as  near  the  apex  of  the 
deforming  angle  as  possible  and  followed  by  a  proper  adjustment  of  the 
sawed  surfaces. 

Amputation  is  a  last  resort.  It  is  to  be  employed  only  when  total  loss 
of  function  or  extensive  ulceration  occurs.  This  method,  however,  has  been 
practically  abandoned. 

Compound  methods  are  frequently  employed,  as,  for  instance,  tenotomy 
and  correction  under  anesthesia,  or  osteotomy  and  subsequent  mechanic 
treatment.  Manipulation  under  anesthesia,  tenotomy  and  myotomy  (Phelps), 
and  retention  by  means  of  plaster-of-Paris  bandages  are  specially  useful  in 
congenital  talipes. 

Some  forms  of  fibrous  ankylosis,  as  well  as  false  ankylosis,  may  be 
treated  by  one  or  both  of  the  first  two  methods,  namely,  instrumental  correc- 
tion or  tenotomy.  Bony  and  cartilaginous  ankylosis,  however,  and  some 
forms  of  fibrous  ankylosis  will  require  resection  or  osteotomy. 

Movable  Bodies  in  Joints. — These  are  the  consequence  either  of  in- 
juries or  of  arthritis  deformans.  When  the  result  of  injuries,  portions  of 
the  articulating  surfaces  or  interarticular  cartilages  are  torn  off.  These  may 
remain  attached  and  become  subsequently  detached  by  sudden  movements 
of  the  limb.  They  are  rarely  observed  elsewhere  than  in  the  knee-joint  or 
the  elbow-joint.  When  the  result  of  arthritis  deformans,  they  may  have 
their  origin  in  the  pediculated  synovial  villi.  They  may  likewise  be  found 
in  the  sheaths  of  tendons  which  have  been  the  seat  of  tendovaginitis,  as  ^^'ell 
as  in  bursae  following  bursitis.  Here  they  occur  as  quite  small  rounded  bodies 
which  resemble  grains  of  rice  (oryzoid  bodies) .  Or,  movable  bodies  the  result 
of  arthritis  deformans,  may  occur  in  consequence  of  the  pediculation  of  the 
free  edge  of  cartilaginous  and  bony  proliferations,  which  subsequently  become 
torn  off.  Even  after  becoming  loosened  they  ma}'  continue  to  grow,  receiving 
their  nourishment  from  the  synovial  fluid. 

Diagnosis. — The  symptoms  of  movable  body  in  a  joint  depend  on  (I) 
the  size  of  the  body;  (2)  the  particular  joint  involved.  Large  bodies  give  rise 
to  much  less  disturbance  than  small  ones.  The  latter,  by  becoming  pinched 
between  the  articular  surfaces,  cause  a  sudden  arrest  of  the  movements  of  the 
limb,  and  more  or  less  pain.  The  discomforts  arising  from  pain  in  the  joint 
are  much  greater  in  the  case  of  the  knee  than  in  that  of  the  elbow.  In  the  case 
of  the  latter,  the  pain  is,  as  a  rule,  not  very  severe;  on  the  contrary,  in  the 
case  of  the  former,  it  may  be  sufficiently  acute  to  cause  the  patient  to  swoon. 
In  many  cases  the  movable  body  becomes  fixed  in  some  recess  of  the  joint  where 
it  does  not  interfere  with  the  joint  functions,  and  thus  all  symptoms  are  absent 
for  a  long  period  of  time. 

Palpation  is  employed  to  establish  the  presence  of  the  movable  body.  This 
may  be  difficult,  owing  to  the  fact  that  in  some  localities  thick  overlying  parts 
intervene.  The  patient  will  usually  be  able  to  locate  the  body  when  every 
effort  on  the  part  of  the  surgeon  to  do  so  has  failed. 

The  treatment  consists  in  removal  of  the  movable  body  by  incision,  after 
its  presence  and  location  have  been  assured  positively  (see  Regional  Surgery). 


THE   JOINTS  163 

Synovitis  of  the  Sheaths  of  Tendons,  Tendovaginitis,  Tendosyno= 
vitis. — TentUnous  sheaths  are  hncd  with  a  synovial  membrane  which  is 
identical  in  every  particular  with  that  which  lines  the  interiors  of  joints. 
Analogous  conditions  involving  the  necessity  of  preventing  friction  exist  in 
tendons  and  joints.  Certain  tendon-sheaths  have  direct  communication  with 
the  joint  (the  popliteus  with  the  knee-joint,  and  the  long  head  of  the  biceps 
with  the  shoulder-joint). 

Tendovaginitis  assumes  the  same  forms  as  synovitis  of  the  joints.  If 
the  disease  is  due  to  a  direct  injury,  hemorrhage  may  accompany  the  effusion 
of  serum.  Fibrinous  deposits  in  the  sheath  give  rise  to  crepitating  sounds 
which  are  quite  characteristic.  The  affection  has  its  origin  in  excessive  strains 
on  the  tendons  when  certain  difficult  and  unusual  movements  are  executed.  It 
is  commonly  seen  about  the  wrist  in  tennis  players  from  the  use  of  the  racket, 
and  in  plasterers  from  the  use  of  the  trowel.  The  fibrous  type  is  best  treated 
by  immobilization  and  counter-irritation  with  tincture  of  iodin  for  several  days. 
The  serous  variety,  showing  the  swelling  and  not  the  crepitation,  requires  the 
use  of  splints  and  lotions.  The  few  cases  that  are  wholly  or  in  part  rheumatic 
in  origin  require  constitutional  medication  as  well. 

Suppurative  Tendovaginitis.— Suppurative  inflammation  of  the  sheaths 
of  tendons  is  almost  exclusively  observed  in  cases  of  septic  wounds  involving 
these  sheaths.  It  may  be  exceedingly  rapid  in  its  progress,  a  septic  infection 
at  a  phalanx  reaching  the  forearm  in  twenty-four  hours  by  this  route.  Nec- 
rosis of  the  tendon  also  occurs  very  rapidly  under  these  circumstances.  If 
the  tendon  escapes,  granulations  spring  up,  and  both  tendon  and  sheath  become 
adherent  in  the  resulting  cicatrix.  Early  and  free  incision  and  antiseptic  treat- 
ment are  imperatively  demanded. 

Tuberculous  Tendovaginitis. — This  occurs  very  rarely  as  a  primary 
affection,  but  is  the  result  of  extension  from  neighboring  diseased  bones  and 
joints. 

Papillary  tendovaginitis  is  a  hyperplastic  inflammation  of  the  sheaths 
of  tendons.  The  papillae  become  separated  from  their  attachments  by  con- 
strictioi^  forming  the  so-called  oryzoid  or  rice  bodies.  They  probably  arise 
from  the  small  synovial  recesses  which  are  found  in  the  normal  state  closely 
attached  to  the  tendinous  sheaths.  The  extensor  tendons  of  the  fingers  are 
most  frequently  affected.  The  bacilli  of  tuberculosis  have  recently  been  demon- 
strated in  these  rice  bodies.  An  excision  of  the  affected  part  of  the  sheath  is 
the  treatment  advised  for  these  cases. 

QangHons. — These  are  protrusions  of  the  synovial  sheaths  through  their 
fibrous  coverings.  They  are,  in  fact,  hernial  pouches.  A  strain  is  a  frequent 
cause.  Clinically  there  are  seen  semispheric  tumors  of  more  or  less  density 
that  do  not  involve  the  skin  but  move  with  the  tendons.  They  have  the  same 
inflammatory  actions  as  joints.  They  .are  to  be  differentiated  from  chronic 
dropsy  of  the  sheath  both  by  the  absence  of  fluctuation  in  the  solid  variety 
and  by  the  correspondence  of  the  swelling  to  the  length  and  breadth  of  the 
sheath  in  the  dropsical  conditions  of  the  tendons.  When  the  tension  is  very 
great,  fluctuation  is  absent  in  the  gelatinous  form  as  well.  Some  of  these  gan- 
glions though  appearing  near  the  tendon,  when  dissected  out  A\ill  be  found  to 
arise  by  a  pedicle  from  the  joint,  and  are  really  protrusions  of  the  joint 
synovial  membrane.     The  acute  cases  are  simply  serous  in  character,  as  a  rule, 


164  INJURIES   AND    DISEASES    OF   SEPARATE    TISSUES 

and  require  only  subcutaneous  puncture.  Other  cases  of  greater  densit}' are  of  a 
serofibrinous  t>pe  and  should  be  dissected  out.  Still  others  are  tuberculous 
in  character  and  progressive  in  their  course,  requiring  a  prompt  radical  excision 
before  neighboring  tendon-sheaths  and  joints  are  involved. 

Bursitis. — The  bursae  mucosae  are  lined  ^^ith  synovial  membrane,  which 
may  become  the  subject  of  inflammation.  This  may  be  serous,  serofibrinous, 
or,  in  the  case  of  the  prepatellar  bursa,  suppurative,  as  in  joint  synovitis.  These 
bursae  are  sometimes  situated  near  large  joints,  and  inflammatory'  processes 
may  extend  from  one  to  the  other,  as,  for  instance,  the  bursa  of  the  iliopsoas 
and  of  the  hip-joint,  and  that  of  the  subscapularis  and  of  the  shoulder-joint. 
Rarely  a  bursa  may  be  the  seat  of  a  primarv-  tuberculous  synovitis. 


SECTION  111 
GUNSHOT  INJURIES 

Definition. — The  term  "gunshot  injury"  is  usually  applied  to  those  in- 
juries caused  by  missiles  propelled  by  means  of  a  sudden  violent  expansive 
force.  Besides  injuries  which  result  from  projectiles  discharged  from  some 
of  the  various  kinds  of  guns  and  firearms  in  common  use,  those  which  result 
from  missiles  projected  by  violent  explosive  force  other  than  that  imparted  to 
them  by  the  aid  of  guns,  such,  for  instance,  as  fragments  of  a  shell,  canister 
shot,  and  shrapnel  bullets,  as  well  as  substances  propelled  by  the  explosion 
of  military  mines,  are  comprehended  under  the  same  term.  In  fact,  any  sub- 
stance driven  with  sufficient  velocity,  and  hence  violence,  through  the  agency 
of  an  expansive  force  will  produce  injuries  which  to  all  intents  and  purposes 
are  gunshot  injuries.  The  great  majority  of  wounds  of  this  class  coming  under 
the  care  of  the  surgeon,  however,  are  caused  by  bullets  from  such  portable 
firearms  as  rifles,  pistols,  and  muskets. 

The  General  Characteristics  and  Distinguishing  Features  of  Qun= 
shot  Injuries. — Every  conceivable  variety  of  injury  capable  of  being  in- 
flicted on  the  human  frame  by  violently  propelled  obtuse  bodies  is  embraced 
in  gunshot  injuries.  The  leading  characteristic  of  these  lesions  is  the  constant 
presence  of  the  features  of  either  contusion  or  laceration,  or  of  both,  in  connec- 
tion with  the  injur>\  The  former  may  be  present  as  a  simple  bruise  of  the 
surface  from  contact  with  a  spent  ball,  or  it  may  involve  complete  destruction 
of  deep-seated  structures  or  organs  with  very  httle  superficial  injury.  The 
elements  of  both  contusion  and  laceration  enter  in  the  case  of  penetrating  gun- 
shot wounds,  though  these  may  vary  from  mere  division  of  the  skin  to  the 
most  extensive  shot  canals,  or  the  shattering  of  the  tissues  with  which  the  bullet 
may  come  in  contact.  The  variations  present  in  gunshot  injuries  in  general 
depend  on  the  following:  (1)  The  physical  qualities  of  the  projectile.  These 
relate  to  its  form,  weight,  the  material  of  which  it  is  composed,  its  dimen- 
sions, volume  and  density.  (2)  The  qualities  which  the  missile  derives  from 
the  arm  from  which  it  is  projected,  namely,  its  velocity  and  rotation.  (3) 
Qualities  imparted  to  the  missile  during  its  flight,  such  as  the  resistance  offered 
by  the  air  through  which  it  passes,  its  passage  through  media  of  different 
densities  or  through  resisting  bodies,  deviations  from  its  normal  course  or  from 
the  direction  of  its  longitudinal  axis  (ricochet  shots),  etc.  (4)  The  heat  devel- 
oped during  the  flight  of  the  buflet,  which  has  been  supposed  by  some  to  affect 
the  wound.  In  addition,  the  quality  of  poison  added  to  the  bullet,  from  which 
it  is  transferred  to  the  wound,  may  have  to  be  taken  into  account.  (5)  Con- 
ditions pertaining  to  the  part  of  the  body  struck,  such,  for  instance,  as  the 
relative  position  of  the  part  struck  to  the  missile  (the  angle  of  impact),  the 
location  of  the  injury,  and  the  course  taken  by  the  projectile  after  it  enters 
the  body.  (6)  The  entrance  of  foreign  bodies  into  the  wound,  such  as  por- 
tions of  clothing,  gun  wadding,  splinters  of  wood,  etc. 

165 


166  GUNSHOT    INJURIES 

The  Shape  and  Size  of  the  Projectile. — In  the  case  of  the  larger  pro- 
jectiles the  crushing  effects  and  disturbances  of  neighboring  parts  are  such 
that  but  slight  influences  are  exerted  by  the  forms  of  these  projectiles  on  the 
character  of  the  injuries  that  they  inflict.  On  the  other  hand,  the  wounds 
made  by  the  smaller  projectiles,  or  those  discharged  from  rifles,  pistols,  etc., 
present  variations  according  as  the  bullet  is  spheric,  of  the  combined  cylindric 
and  pointed  arch  form  (the  so-called  cylindro-ogival),  or  cylindroconoidal. 
The  diameter  of  the  bullet  likewise  exercises  an  important  influence  on  the 
character  of  the  injury.  In  the  case  of  the  spheric  bullet  there  is  more  or  less 
of  a  diffused  concussion  effect  radiating  from  the  point  of  impact  (Long- 
more).  This  effect  is  less  marked  in  the  pointed  arch  and  cylindrocon- 
oidal forms,  and  progressively  lessens  as  the  diameter  of  the  bullet  is  decreased. 
The  latter  circumstance,  namely,  the  decrease  in  diameter,  as  well  as  the 
smoothness  of  surface,  such  as  exists  in  the  steel-mantled,  nickel-mantled, 
and  copper-mantled  bullets,  greatly  increases  the  penetrative  power  of  the 
projectile. 

The  question  of  deformation  of  the  projectile  has  a  direct  bearing  on 
the  character  of  the  injury.  The  intrinsic  tendency  of  the  round  bullet  to 
deformation  is  slight,  on  account  of  its  minimum  amount  of  so-called  "in- 
ternal energy";  in  the  modern  oval  and  long  bullet  this  tendency  is  greater 
and  has  necessitated  the  application  of  a  jacket  or  mantle  to  prevent  marked 
bending  and  splitting.  These  deformations  are  caused  by  the  resistance  met  with 
in  the  tissues  resulting  in  a  reciprocal  back  action  on  the  projectile  through 
which  a  portion  of  its  intrinsic  power  is  converted  into  deformation  and  heat 
in  such  a  manner  that  both  effects  are  equal  (Reger).  The  velocity 
being  the  same,  in  the  case  of  the  unprotected  bullet  the  deformity  increases 
with  the  resistance;  in  the  case  of  the  protected  bullet  the  heat  increases. 
Again,  the  resistance  being  equal  and  the  velocity  increasing,  the  deformity  in- 
creases in  the  unprotected  bullet  and  the  heat  increases  in  the  protected  bullet. 

The  deformity  of  the  projectile  influences  the  effect  of  the  bullet  in  a 
marked  degree.  The  effects  are  more  extended,  and,  as  a  result  of  an  increase 
of  the  resistance  and  a  decrease  of  the  penetrating  power,  the  deformity  still 
further  increases,  so  that  the  bullet  either  lodges  in  the  tissues,  or  in  emerg- 
ing, causes  the  most  bizarre  effects.  This  is  specially  true  in  cases  in  which 
the  bullet  has  passed  through  other  living  bodies  or  through  breastworks. 
If  the  deformed  missile  has  sufficient  energy  remaining,  it  may  still  exert  a 
radiating  concussion  (explosive  effect). 

The  effect  known  as  mushrooming  is  a  still  more  pronounced  deforma- 
tion, and  is  more  especially  marked  in  the  so-called  Dumdum  bullets.  This 
effect  may  take  place  in  jacketed  projectiles  that  strike  hard  objects,  either 
before  or  after  they  enter  the  body,  or  it  may  be  produced  by  tampering  with 
the  jacket  of  the  projectile. 

In  the  majority  of  cases  gunshot  wounds  inflicted  by  the  modern  small- 
bore, elongated,  high-velocity  projectile  have  two  apertures,  one  made  by  the 
entrance  of  the  missile  and  the  other  by  its  exit.  As  a  rule,  the  wound  of 
entrance  is  smaller  than  the  wound  of  exit. 

The  wound  of  entrance  is  modified  by  the  manner  in  which  the  missile 
comes  in  contact  with  the  surface  of  the  body.  Changes  of  position  with 
reference  to  the  long  axis  in  the  case  of  the  modern  projectile  cause  the  latter 


CHARACTERISTICS    AND    DISTIXGUISHIXG    FEATURES 


167 


to  strike  more  or  less  sideways,  this  "  cross-hit "  causing  a  wound  which  dif- 
fers materially  from  the  small  and  smootli-edged  ajjerture  present  when  the 
intact  ball  strikes  with  its  long  axis  directly  at  right  angles  to  the  surface. 
Cross-hits  are  the  result  either  of  the  striking  of  the  bullet  on  some  object, 
such  as  a  tree  branch,  stone,  etc.  (ricochet  shots),  or  of  its  passing  through 
several  different  media,  or  through  bodies  that  resist  its  course  more  or  less 
strongly.  It  is  therefore  a])parent  that  a  ricochet  shot,  if  it  retains  sufficient 
energy,  may  do  a  greater  amount  of  damage  than  if  it  had  struck  in  its  long 


Fig.  28. — Bullet  Wouxd  in  a  Japanese  Soldier  Received  while  Lying  Down. 
Photographed  after  the  battle  of  Liao-yang.     A  furrow  is  made  in  the  upper  arm  and  a  wound  of  entrance 

and  exit  in  the  forearm. 

diameter.  Usually,  however,  the  greater  part  of  the  velocity  of  the  missile 
is  lost  either  by  its  striking  the  object  on  which  it  ricochetted,  or  by  the 
greater  resistance  which  the  air  affords  to  its  passage  in  its  changed  position, 
or  by  both,  and,  in  addition,  the  influence  of  rotation  imparted  to  it  by  the  rifling 
in  the  barrel  of  the  arm  is  lost ;  the  result  is  that  the  shot  does  much  less  damage 
than  if  projected  from  the  same  distance  without  meeting  resisting  or  deflect- 
ing bodies  on  the  way  and  striking  in  its  long  diameter. 


168 


GUNSHOT   INJURIES 


The  wound  of  exit  is  increased  in  size  by  the  tissues  driven  out  with  the 
ball  (fragments  of  bone,  portions  of  muscular  tissue,  etc.),  by  the  alterations 
in  the  direction  of  the  long  axis  which  almost  invariably  occur  and  which, 
when  considerable,  the  power  of  rotation  still  being  retained,  may  cause 
extensive  destruction  of  both  bone  and  soft  parts,  as  well  as  by  deformations 
of  the  projectile  itself.  Variations  in  the  size  and  shape  of  the  wound  of  exit 
also  depend  on  the  elasticity  and  mobility  of  the  part.     In  organs  in  which 


Fig.  29. — Fragments  of  Mantles  Removed  from  Bullet  Wounds  (after  a  photograph  from  the  Medical 

Department  of  the  Japanese  Army). 

there  is  considerable  fluid,  such  as  the  brain,  the  heart,  the  stomach  and 
intestines,  the  hydrodynamic  pressure  effect  influences  the  action  of  the  pro- 
jectile in  a  marked  degree;  this  effect  serves  also  to  explain  the  radiating 
concussion  or  explosive  action  of  projectiles  on  the  tissues  in  general.  The 
hydrodynamic  theory  rests  on  the  incompressibility  of  water  and  the  re- 
sulting narrowing  of  the  space  through  which  the  transfer  of  pressure  in  all 


Fig.  30. — Bullet  Wound  Received  by  a  Japanese  Soldier  at  the  Battle  of  Liao-yang. 

The  shot  struck  at  the  range  of  about  500  yards  while  the  soldier  was  kneeling.  The  wound  of  en- 
trance is  about  normal  in  size ;  the  wound  of  exit  is  very  large  and  illustrates  the  destructive  effects  of 
the  modern  projectile  at  short  range.     The  bone  was  broken  in  this  case. 

directions  takes  place.  The  more  fluid  present  in  the  tissues  or  organs  struck 
and  the  shorter  the  distance  at  which  the  shot  is  fired,  the  more  intense  the 
effect.  For  instance,  a  shot  at  close  range  may  almost  completely  empty 
the  skull  of  its  contents.  In  addition  to  the  increase  in  the  effect  due  to 
increase  in  the  fluid  present  and  the  velocity  of  the  projectile,  increase  in 
the  caliber  and  deformation  of  the  latter   heightens    the    damaging   effects. 


CHARACTERISTICS   AND    DISTINGUISHING    FEATURES 


169 


Experiments  show  that  an  8  mm.  steel -man  tied  projectile  at  100  meters  gives 
a  hydrodynamic  pressure  of  6.4  atmospheres,  while  a  projectile  of  11  mm.  at 
the  same  distance  gives  a  pressure  of  8  atmospheres  (Kikuzi). 

Deformations  of  modern  projectiles  occurring  after  they  enter  the  body 
arc  due  exclusively  to  impact  against  bone;  in  wounds  of  soft  parts  alone  the 
form  of  the  missile  is  not  altered.  In  4.5  per  cent  of  all  hits  deformation  takes 
(ilace  (C  o  1  e  r  and  S  c  h  j  e  r  n  i  n  g).  A  much  larger  proportion  of  hits  of 
bone  than  the  above  percentage  represents,  however,  actually  takes  place. 
In  certain  parts  of  bone  which  are  harder  than  others,  such,  for  instance,  as  the 
crest  of  the  tibia,  the  linea  aspera 
femoris,  etc.,  more  deformity  of 
the  missile  takes  place,  while 
bullets  lodged  in  the  epiphyses 
remain  comparatively  intact. 

The  extent  of  the  injury  is  in 
direct  proportion  to  the  deforma- 
tion of  the  bullet.  Wherever 
there  is  marked  shattering  of  the 
projectile,  there  is  extensive  de- 
struction of  bone  and  a  corre- 
spondingly large  wound  of  exit. 
When  mushrooming  of  the  modern 
projectile  takes  place  as  the 
result  of  disturbances  of  the 
mantle,  the  effects  are  in  no  way 
less  than  the  wounds  made  by 
the  old-time  leaden  mushroomed 
bullet. 

The  soft  tissues  with  which 
firearm  projectiles  come  in  con- 
tact are  often  greatly  diminished 
in  vitality,  and  more  or  less 
sloughing  is  likely  to  occur.  In 
addition  to  this,  their  repair  may 
be  interfered  with  by  infectious 
material  carried  in  by  the  bullet, 
as  well  as  by  the  presence  of 
foreign  bodies.  In  injuries  of 
long  bones,  in  case  the  diaphysis 

is  struck,  even  at  ranges  of  from  1500  to  2000  meters,  there  is  a  shattering  of 
the  bone  as  a  constant  effect.  On  the  other  hand,  smooth  bullet  canals  are 
found  in  the  epiphyses  even  at  as  short  a  range  as  200  meters  (C  o  1  e  r  and 
S  c  h  j  e  r  n  i  n  g).  The  claims  made  th"at  the  modern  small-bore  high-velocity 
missile  is  a  more  humane  weapon  than  the  old  large-caliber  rifle  with  its  bare 
leaden  bullet,  as  based  on  the  experiments  of  B  r  u  n  s  and  H  a  b  e  r  t ,  are 
not  borne  out  by  the  observations  of  C  o  1  e  r  and  Schjerning.  The 
explanation  of  this  discrepancy  seems  to  lie  in  the  fact  that  the  former  experi- 
menters, in  order  to  overcome  the  difficulties  inherent  in  making  experimental 
shots  at  long  range,  shortened  the  distance  and  projDortionately  reduced  the 


Fig.  31. — Bullet  Wound  Received  by  a  Japanese 
Soldier  at  the  Battle  of  Liao-yang. 
The  shot  was  received  at  a  range  of  between  700  and 
800  yards  while  the  soldier  was  kneeling.  The  diameter 
of  the  wound  of  exit  as  shown  is  3i  inches.  The  bone 
was  shattered.  Ttie  wound  of  entrance  at  the  back  of 
the  arm  is  circular. 


170 


GUNSHOT   IXJURIES 


charges,  thereby  reducing  the  rotatory  velocity  of  the  projectile.  It  may  be 
confidently  stated,  however,  that  in  the  case  of  injuries  of  the  soft  parts  alone 
the  advantages  are  altogether  in  favor  of  the  modern  arm  provided  its  projec- 
tile strikes  the  body  with  the  mantle  or  jacket  intact.  Under  these  circum- 
stances, and  in  the  absence  of  injury  of  the  bone,  smaller  wounds  of  entrance 
and  exit  are  made  and  less  damage  to  the  soft  parts  results. 

When  but  one  aperture  exists,  it  is  fair  to  presume  that  the  ball  remains 
in  the  body.  The  presence  of  two  openings,  however,  does  not  necessarily 
mean  that  the  bullet  has  made  its  exit;  only  a  fragment  thereof  may  have 
escaped,  or  two  shots  may  have  been  discharged  from  different  directions, 
both  projectiles  remaining  in  the  body.     One  ball  may  produce  several  wounds 

of  entrance  and  exit,  as  in  the  case  of 
a  gunshot  wound  of  the  arm  and  chest, 
or  of  a  flexed  limb,  or  of  both  lower 
extremities  struck  by  the  same  missile, 
the  latter  passing  through  one  and 
lodging  in  the  other.  The  missile  may 
graze  one  part  of  an  extremity,  making 
a  furrow,  and  penetrate  or  perforate 
another  (Fig.  2S).  Fragments  of  man- 
tle torn  from  the  projectile  may  re- 
main in  the  tissues,  the  projectile  itself 
escaping  (Fig.  29).  The  circumstance 
of  fracture  of  the  bone  adds  greatly  to 
the  destructive  effects  of  the  shot,  not 
only  on  account  of  the  radiating  con- 
cussion (explosive  effect)  of  the  ar- 
rested bullet,  but  also  on  account  of 
the  tearing  and  mangling  of  the  tissues 
from  the  deformation  which  the  bullet 
undergoes  and  from  the  disturbing  in- 
fluences of  the  bone  fragments.  These 
sometimes  occur  in  a  most  extraordi- 
nary degree  when  the  shaft  of  the 
bone  is  struck,  but  in  a  less  degree 
when  the  epiphysis  is  the  part  injured 
(Figs.  30  and  31).  With  loss  of  veloc- 
ity and  of  rotatory  force  before 
striking,  such  as  occurs  at  long  range, 
or  at  a  shorter  range  in  a  ricochet 
shot,  the  iDullet  may  strike  directly  on  a  long  bone,  as,  for  instance,  the  tibia, 
and  lodge  in  the  limb,  the  bone  escaping  fracture.  If  to  this  are  added  the 
effects  of  a  deformed  bullet,  the  conditions  present,  as  shown  in  figure  32,  will 
obtain.  A  bullet  that  has  ricochetted  and  become  altered  in  shape  by  impact 
against  the  object  which  deflects  it  from  its  course,  and  finaUy  strikes  as  a 
cross-hit,  Tvall  inflict  such  an  injury  as  that  shown  in  figure  33. 

In  an  engagement  in  which  both  rifle  projectiles  and  shrapnel  bullets  are 
employed  it  is  sometimes  difficult  to  determine  which  wounds  are  inflicted 
by  the  latter  and  which  by  the  former,  especially  under  circumstances  where 


Fig.  32. — BrLLET  Wound  of  the  Leg  Received 
BY  A  .Japanese  Soldieb  at  the  Battle  of 

LlAO-YANG. 

The  wound  of  entrance  as  shown  is  1^  inches 
long  and  i  of  an  inch  wide.  The  wound  shows  the 
usual  appearance  of  a  cross-hit  (querschlager)  from 
a  ricochet  shot  with  deformation  of  the  bullet. 


SYAIPTOMS   OF    GUNSHOT   WOUNDS 


171 


the  best  opportunities  are  afforded  for  ricochet  shots,  namely,  with  the  men 
on  the  firing-lino  either  kneeling  or  lying  down  (compare   Figs.  34  and   35). 

The  Symptoms  of  Gunshot  Wounds. — The  more  or  less  constant 
symptoms  include  (1)  pain;  (2)  shock;  (3)  primary  hemorrhage.  The 
occasional  symptoms  are  (1)  lodgment  of  the  bullet;  (2)  powder  burns;  (3) 
multiplicity  of  wounds. 

The  symptom  pain  is  an  exceedingly  variable  one.  Its  intensity  depends 
on  the  part  struck  and  the  circumstances  under  which  the  injury  is  received. 
Only  the  most  vague  recollection  of  the  amount  of  pain  suffered  at  the  moment 
of  being  struck  is  recalled  if  the  injury  is  inflicted  during  periods  of  excite- 
ment, as  in  a  battle  or  in  a  duel. 
A  condition  of  local  anesthesia 
may  l^e  present  alDout  the  injured 
parts. 

More  or  less  shock  is  usually 
present.  This,  even  in  the  case  of 
the  modern  projectile,  is  usually 
sufficient  to  disable  the  injured 
one,  in  spite  of  the  assertion  to 
the  contrary  so  frequently  made. 
The  dra\Mi  or  anxious  facial  ex- 
pression is  a  fairly  good  index  of 
the  gravity  of  the  shock  present. 

The  sjnmptom  of  primary  hem- 
orrhage, particularly  of  the  inter- 
nal variety,  may  be  sufficient  to 
threaten  life.  In  all  probability 
the  majority  of  deaths  on  the  field 
of  battle  are  due  to  injuries  of 
blood-vessels  in  the  interior  of 
the  trunk.  Of  fatal  external 
hemorrhage  or  that  which  is  ac- 
cessible to  the  surgeon,  and 
which,  seen  in  time,  ma}'  be  ar- 
rested, such  as  occurs  in  injuries 
of  the  brachial  and  femoral  arter- 
ies, the  instances  are  rare  (L  o  n  g  - 
m  o  r  e ,  3  per  cent ;  Otis,  0.05 
per  cent).      Aside  from  the  two 

classes  of  cases  mentioned,  in  which  death  may  take  place  at  once,  the 
primary  hemorrhage  from  a  gunshot  wound  is  rather  unimportant.  Even 
when  vessels  of  considerable  size  are  injured  by  the  small-caliber  projectile 
the  hemorrhage  tends  to  spontaneous  arrest. 

The  occurrence  of  secondary  hemorrhage  may  be  due  to  some  general 
cause,  such  as  hemophilia,  or  the  presence  of  constitutional  conditions  due  to 
prolonged  campaignmg  (scurv}^,  anemia,  etc.)  in  military'  practice.  ]\Iore  fre- 
quently, however,  it  is  due  to  local  causes,  among  which  may  be  mentioned 
ulceration  or  the  sloughing  of  the  coats  of  a  vessel  from  injury  of  the  vessel,  this 
injury  involving  only  its  outer  coat,  the  remainder  of  the  vessel  givmg  way 


Fig.   33. — Bullet  Wound.     Japanese  Soldier 
Wounded  at  the  Battle  of  Liao-yang. 

The  soldier  was  shot  at  the  range  of  about  200  yards 
while  kneeling.  The  large  wound  of  entrance  suggests 
that  the  bullet  was  deformed  before  striking,  or  that  it 
struck  as  a  cross-hit. 


172 


GUNSHOT   INJURIES 


several  hours  or  days  later.  In  former  times  it  was  most  frequently  due  to 
the  supervention  of  septic  arteritis  in  a  suppurating  bullet  track.  It  may 
be  due  to  the  continued  pressure  of  a  lodged  projectile,  or  of  a  fragment  of  a 
projectile  or  l^one,  the  sharp  or  ragged  edge  of  which  in  time  causes  erosion. 

The  lodgment  of  the  missile  occurs  with  much  less  frequency  in  the 
case  of  high-velocity  small-caliber  projectiles  than  in  the  old-fashioned,  large, 
smooth-bore  guns,  and  in  the  pistol-l^all  wounds  of  civil  life.  A  missile  from 
a  modern  small-caliJDer  rifle  seldom  lodges  in  the  tissues  except  when  fired  at 
long  range,  or  when  it  meets  with  intervening  objects  which  retard  its  flight 
and  lessen  its  velocity. 

The  presence  of  powder  burns  is  observed  in  gunshot  injuries  occurring 
at  short  range  and  on  exposed  portions  of  the  body,  when  the  old-fashioned 
black  powder  is  used.  When  the  wound  is  inflicted  by  a  revolver,  the  "  pow- 
der brand"  will  bear  a  rather  constant  relation  to  the  wound,  according  to 


^ 

1 

^%^ 

v'*- 

tM^C 

^ 

r 

1 

jAl 

"If 

Is 

m 

Fig.  34. — Shrapnel  Bullet  Wound,  Received  by  a  Japanese  Soldier  at  the  Battle  of 

LlAO-YANG. 

The  wound  of  exit,  6  inches  long  by  4  inches  wide,  is  shown  in  the  illustration.     The  bone  was  shattered. 

the  position  of  the  hammer  of  the  weapon  when  the  latter  is  fired;  these  two 
wiU  correspond  to  each  other  (Fish)  .  The  degree  of  powder  burn  will 
be  modified  by  the  distance;  a  relatively  short  range  will  result  in  superficial 
burning  of  the  tissues,  and  a  range  sufficiently  long  to  enable  the  parts  to 
escape  the  flame  of  the  burning  powder  may  yet  be  sufficiently  close  to  permit 
grains  of  unburned  powder  to  lodge  in  and  beneath  the  skin,  causing  tattoo 
marks.  These  grains  of  powder  may  be  the  means  of  conveying  septic  infec- 
tion, particularly  tetanus  and  malignant  edema.  The  powder  brand  will 
be  absent  in  the  case  of  smokeless  powder. 

The  subject  of  multiplicity  of  wounds  has  already  been  referred  to  (vide 
supra).  Multiple  wounds  occur  much  more  frequently  since  the  introduction 
of  the  modern  small-bore  rifle,  and  depend  on  the  increased  velocity  and  high 
penetration  of  projectiles  from  this  class  of  firearms.  The  arms  and  chest 
seem   to  be   involved   most  frequently  in  simultaneously  inflicted  multiple 


DIAGNOSIS  OF   GUNSHOT   WOUNDS 


173 


wounds  Either  the  uppcn-  or  the  lower  extremity,  when  flexed,  offers  oppor- 
tunity for  the  occurrence  of  multiple  wounds  from  a  smgle  missile  as  a 
primary  compUcation. 

The  question  of  infection  of  a  gunshot  wound  is  of  special  importance 
That  this  may  occur  through  the  medium  of  an  infected  bullet  has  been  placed 
bevond  dispute  bv  the  classic  experiments    of  L  a  G  a  r  d  e  ,  of  the  United 
States  Army.     That  all  bullets  are  not  infected  is  true  ;   it  is  equally  true 
that  all  infected  bullets  do  not  give  rise  to  suppuration.     In  the  case  of  the 
latter  the  question  is  simply  one 
of  the  relations  existing  between 
the    virulence    of    the    infecting 
microorganism  on  the  one  hand, 
and  the  vital  resistance   of   the 
patient   on   the    other.     The    in- 
fection   from    clothing,    portions 
of  which  may  be   carried  in  by 
the  bullet,  is  of   greater  import- 
ance, since  it  is  far  more  likely  to 
occur  than  infection  from  the  bul- 
let.    Yet  even  this  method  of  in- 
fection   is    not    so    common    as 
would  be  supposed.    Meddlesome 
fingering  and  probing,  even  under 
presumably     aseptic    conditions, 
are  far  more  frequently  respon- 
sible for   subsequent  suppuration 
in  gunshot  wounds  than  is  either 

the^  bullet  or  the  pieces  of  cloth- 
ing carried  into  the  wound. 
Diagnosis. — The  character  of 

the  wound  of    entrance,    as  well 

as  of  the  wound  of  exit,  if  such 

is  present,  will  settle  the  question 

of  the  infliction  of  the  injury  by 

a    projectile     from   .a     firearm. 

Difficulty    will    not    infrequently 

be   experienced,  however,  in  de- 
termining   the  character  of  the 

missile,    its    caliber,    etc.       The 

typic   smaH   and   clean-cut  wound  of    entrance 

incidence    with    the   surface   is    a  right   angle. 


Y^a  35  —Bullet  Wound  Received  at  the  Range  of 
■  between  600  AND  700  Yahds  while  the  Soldier 

WAS  Lying. 

The  illustration  shows  the  wound  of  exit  3i  inches 
long  by  2  inches  -nide  (from  a  photograph  taken  under 
the  auspices  of  the  Japanese  Army  Medical  Department 
after  the  battle  of  Liao-yang). 

results    when  the  angle  of 

]\Iore    or  less    pronounced 
incidence    wiin    xne   suiiaue   lo    a.  x^&^x^   ^..^.^.     ^'-i.^  ^  ^  •     -j 

deviations  from  this  are  observed  with  variations  m  the  angle  of  mcidence, 

extension  of  the  range,  and  reduction  of  the  residual  velocity  of  the  projec- 

tUe  from  ricochet.     Still  more  decided  departures  from  the  ^^^^mal  aperture 

of  entrance  are  observed  as  the  result  of  deformations  of  the  bullet  from 

striking  hard  substances,  such  as  rocks,  etc.     In  the  case  of  ^  ^P^e^ic  bulle 

the  wound  of  exit  is  larger  than  the  wound  of  entrance,  for  the  reason  that 

the  explosive  effect  which  the  invaded  tissues  manifest  as  a  result  o  the  hidro- 

dvnanfic  force  initiated  bv  the  invading  missile  forces  the  overlying  mteg- 


174  GUNSHOT   INJURIES 

iiment  away  from  the  supporting  structures  beneath,  as  the  pressure  takes 
place  from  Avithin  outward,  and  an  irregularly  shaped  and  larger  opening 
results.  When  the  injury  is  caused  by  the  cylindroconoidal  or  the  cylindro- 
ogival  projectile  of  moderate  size,  and  this  pursues  a  normal  flight  with  prac- 
tically undiminished  residual  velocity  and  encounters  soft  tissues  only,  pass- 
ing through  the  latter  almost  unimpeded,  it  may  be  difficult  to  distinguish 
the  wound  of  exit  from  that  of  entrance.  Departures  from  these  conditions, 
however,  Avill  give  rise  to  varying  appearances.  Slight  ragged  and  radiating 
slits  from  the  margins  are  due  either  to  the  escape  of  small  fragments  of  bone, 
of  fragments  of  the  mantle  and  lead  kernel  of  the  bullet,  or  to  the  loss  of  sup- 
port beneath  the  skin.  Or  a  wound  several  times  as  large  as  the  wound  of 
entrance  may  be  present,  signifying  the  occurrence  of  a  bone  lesion.  Dif- 
ferences in  appearance  between  the  wound  of  entrance  and  the  wound  of 
exit  can  be  more  easily  recognized  if  the  wounds  are  examined  early;  later 
on  these  differences  are  more  or  less  obscured  by  the  swelling. 

Indiscriminate  probing  is  to  be  strongly  condemned.  Instances  are  few 
and  far  between  in  which  the  use  of  the  probe  is  justified  prior  to  a  most  care- 
ful and  thorough  aseptic  preparation.  The  information  thus  gained  cannot 
compensate  for  the  risk  of  conveying  infection  from  the  superficial  to  the 
deeper  portions  of  the  wound,  or  of  spreading  infection  that  has  been  already 
conveyed.  Fluoroscop}'^  and  skiagraphy  with  the  Rontgen  ray  have  prac- 
tically replaced  all  other  methods  of  diagnosing  the  location  of  lodged  bullets 
and  the  extent  of  damage  inflicted  on  osseous  structures. 

Prognosis. — This  will  depend  on  (1)  the  parts  of  the  body  traversed 
by  the  projectile  and  involved  in  the  injury;  (2)  the  primary  destructive 
effects;  (3)  the  promptness  with  which  early  assistance  can  be  given  and  the 
subsequent  care  of  the  case;   (4)  the  type  of  arm  employed. 

1.  It  is  estimated  that  of  every  1000  casualties  occurring  in  warfare,  there 
are  about  200  deaths  on  the  field;  and  of  the  remaining  800,  about  110  are 
wounds  of  the  head,  face,  and  neck;  154  of  the  chest,  abdomen,  and  pelvis; 
252  of  the  upper  extremities,  and  285  of  the  lower  extremities  (L  o  n  g  - 
more)  .  Gunshot  wounds  of  the  head,  large  vessels,  spine,  and  viscera 
are  the  most  serious. 

2.  The  circumstances  governing  the  destructive  effects  of  projectiles  have 
already  been  dwelt  on.  In  further  estimating  the  probable  effects  in  the 
individual  case  the  possible  deformation  of  the  bullet  is  of  great  importance. 
Some  missiles  designed  for  hunting  purposes  (express  bullets)  are  purposely 
made  to  flatten  or  mushroom  on  impact,  causing  extensive  mutilation  of  tis- 
sue. This  object  is  effected  by  omitting  the  usual  mantle  or  jacket  covering 
of  the  lead  core  at  the  point  or  nose  of  the  bullet.  The  same  condition  is 
obtained  by  tampering  with  the  bullet,  removing  in  part  the  mantle  or  covering 
therefrom.  The  favorite  method  of  accomplishing  this  among  soldiers  is  to 
grind  away  the  point  of  the  bullet  by  means  of  a  rough  stone.  It  is  needless 
to  say  that  this  is  a  murderous  practice,  and  opposed  to  international  agree- 
ment as  expressed  at  the  Hague  conference  in  1899.  The  possibilities  of  a 
ricochet  shot  and  consequent  deformation  from  this  cause  are  also  to  be 
taken  into  account. 

3.  The  promptness  with  which  early  assistance  can  be  given  and  the  thor- 
oughness of  the  subsequent  care  of  the  case  are  important  factors  in  estimate 


COMPLICATIONS  AND  GENERAL  TREATMENT  OF  GUNSHOT  WOUNDS     175 

iny;  tlu>  iirognosis  of  o;unslK)t  wounds.  In  civil  life  the  hospital  surgeon  can 
usuall\'  control  conditions  that  are  ideal  in  the  care  of  gunshot  wounds.  In 
military  practice  the  exigencies  of  active  service  make  such  demands  on 
the  surgeon  as  to  render  it  impossible  in  most  instances  for  him  to  do  more 
at  first  than  to  ajiply  a  first-aid  packet  to  an  infected  wound,  and  even  this 
is  most  frc(]uently  done  by  a  hospital  corps  man  or  the  wounded  man's 
"bunkie."  In  the  subsequent  treatment  the  exigencies  of  military  life  recjuire 
tlie  movement  of  the  wounded  so  often  that  they  are  robbed  of  the  necessary 
rest,  and  maintenance  of  aseptic  conditions  so  essential  to  the  best  results 
is  well-nigh  an  impossibility. 

4.  The  type  of  arm  employed  governs  the  prognosis  to  a  considerable  ex- 
tent. It  is  unquestionably  true  that  with  improvements  in  the  efficiency  of 
firearms  there  has  resulted  a  lower  mortality,  both  immediate  and  remote. 
The  very  conditions  that  secure  a  higher  velocity  and  longer  range,  likewise 
assure,  on  the  whole,  a  more  humane  weapon,  namely,  smaller  caliber,  higher 
expansive  character  of  the  gases  from  exploded  smokeless  powder,  and,  above 
all,  the  armored  or  jacketed  projectile.  While  it  is  true,  as  previously  stated, 
that  even  with  all  of  these  favorable  conditions  present  the  most  terrific  de- 
struction may  occur,  it  is  also  true  that  the  reverse  of  these  conditions  favors 
still  more  destructive  effects. 

Complications  of  Gunshot  Wounds.— These  are  such  as  relate  to 
wounds  in  general,  and  embrace  inflammations,  gangrene,  secondary  hemor- 
rhage, aneurism,  hospital  gangrene,  pyemia,  tetanus,  erysipelas,  etc.  (see 
Acute  Wound  Diseases).  In  recent  years  these  complications  have  become 
quite  exceptional  in  their  occurrence.  (For  gunshot  injuries  of  separate 
structures  see  individual  structures,  and  for  gunshot  injuries  of  regions  see 
Regional  Surgery,  Vol.  II.) 

The  General  Treatment  of  Gunshot  Wounds.— In  simple  uncom- 
plicated gunshot  wounds  a  sterile  dressing  and  rest  in  the  recumbent  posi- 
tion usually  fulfil  all  the  indications.  In  military  practice,  before  going  into 
battle  provision  for  the  occurrence  and  the  immediate  protection  of  gunshot 
w^ounds  is  made  by  furnishing  each  soldier  with  a  first-aid  dressing  consist- 
ing of  antiseptic  compresses  protected  by  oiled  paper,  and  bandages  and  safety- 
pins  for  securing  these  in  position.  This  dressing  is  applied  either  by  the 
wounded  man  himself,  or,  if  the  wound  is  in  a  part  of  the  body  which  makes 
this  impossible,  by  a  member  of  the  hospital  corps,  an  officer  or  a  comrade,  either 
on  the  spot  or  at  the  dressing  station ;  the  case  is  frequently  not  seen  by  a  medi- 
cal officer  until  hours,  and  sometimes  days,  afterw^ard.  The  most  that  can  be 
said  of  the  first-aid  dressing  is  that,  when  properly  applied,  which  is  not  often 
the  case,  it  serves  to  protect  the  parts  against  further  infection.  Suppurative 
conditions,  when  they  occur,  are  to  be  treated  on  general  principles.  Every 
effort  must  be  made,  in  military  hospitals  particularly,  to  keep  down  the  num- 
ber of  suppurative  cases  as  much  as  possible,  since  sepsis,  under  the  strenu- 
ous conditions  of  active  military  service,  tends  to  spread  with  ever-increasing 
virulence. 

The  question  of  the  removal  of  lodged  bullets  is  an  important  one.  In 
military  practice  the  cases  are  rare  in  which  it  is  necessary  to  remove  the  bul- 
let at  once,  and  even  in  civil  practice  it  happens  frequently  that  more  harm 
may  be  done  by  persisting  in  an  effort  at  removal  than  by  permitting  the 


176  GUNSHOT  INJURIES 

missile  to  remain.  If  time  and  environment  permit,  there  is  no  objection  to 
the  removal  of  a  bullet  that  is  immediately  beneath  the  skin,  provided  asep- 
tic precautions  can  be  rigorously  enforced;  on  the  other  hand,  neither  the 
surgeon  in  charge  of  an  ambulance  in  ci\'il  life,  nor  those  engaged  at  the  dress- 
ing stations  in  military  service,  should  attempt  the  removal  of  lodged  bul- 
lets. A  bullet  superficially  situated  and  easily  felt  may  be  removed  at  the 
field  hospital:  the  removal  of  those  deeply  situated  and  not  definitely  located 
should  not  l)e  attempted  until  a  field  hospital  on  the  line  of  communication 
or  a  base  hospital  is  reached,  where  the  .x-ray  apparatus  can  be  employed  to 
assist  in  the  search. 

Lodged  projectiles  that  cause  pain  by  pressure  on  a  nerve-trunk,  those 
that  interfere  with  the  function  of  a  part,  and  those  that  lie  at  the  bottom 
of  an  infected  bullet  track  should  be  removed.  Irregularly  shaped  fragments 
of  bullets,  pieces  of  shell  and  of  the  covering  or  mantles  of  projectiles,  unless 
these  lie  in  inaccessible  regions,  should  be  removed. 

Attention  has  been  called  to  the  occurrence  of  plumbism  as  a  result  of 
lodged  leaden  missiles  (X  i  m  i  e  r  and  Laval).  This  occurs  with  greater 
frequency  in  case  of  the  lodgment  of  small  shot,  or  of  the  separation  of 
the  bullet  into  fragments,  particularly  where  these  lodge  beneath  the  peri- 
osteum or  in  the  cancellous  tissues,  or  in  the  medullar}^  cavity  of  bones.  The 
symptoms  disappear  on  the  removal  of  the  missiles.  Lead  intoxication, 
even  in  civil  practice,  is  a  very  rare  sequence  of  the  lodgment  of  unprotected 
bullets;  it  will  be  rarer  in  the  future  in  military  practice,  on  account  of  the 
almost  universal  adoption  of  the  mantled  or  protected  bullet,  and  the 
infrequency  with  which  this  lodges  in  the  tissues. 


SECTION    IV 
ACUTE  WOUND  DISEASES 

ERYSIPELAS 

Erysipelas  is  an  infectious  progressive  inflammation  of  the  skin,  with  a 
clearly  defined  and  circumscribed  area.  It  is  characterized  by  a  redness  of 
the  surface,  varying  with  the  intensity  of  the  inflammation,  as  well  as  with 
the  location  of  the  disease.  In  the  scalp,  the  edges  of  the  wound  may  be  pale, 
wdth  some  serous  infiltration  at  the  commencement.  Its  circumscribed  mar- 
gin distinguishes  it  from  phlegmonous  inflammation  of  the  subcutaneous  con- 
nective tissue,  in  which  the  redness  gradually  merges  into  the  surrounding 
healthy  parts.  Where  lymphangitis  follows  erysipelas,  its  well-defined  edges 
are  wanting,  but  in  the  former,  red  lines  or  stripes  will  be  j^resent  correspond- 
ing to  the  Ivmph- vessels. 

Increased  heat  and  swelling  are  present.  The  former  is  demonstrable  by 
means  of  the  surface  thermometer;  the  latter  is  inconsiderable,  and  ordinarily 
scarcely  perceptible,  except  in  localities  where  serous  infiltration  occurs  (scalp, 
etc.).     A  burning  sensation  rather  than  pain  is  complained  of. 

The  disease,  in  its  progress,  varies  as  to  rapidity.  In  advancing,  the  margin 
does  not,  as  a  rule,  maintain  a  symmetric  contour,  but  projections  occur  here 
and  there,  giving  it  an  irregular  outline.  Locality  seems  to  influence  the 
more  or  less  rapid  progress  of  the  disease.  The  direction  taken  is  generally 
that  of  the  lymphatic  current,  though  exceptions  to  this  are  numerous. 

In  erysipelas  bullosum  there  occurs  a  profuse  exudation  of  colored  serum 
in  the  rete  Malpighii,  with  the  formation  of  vesicles.  These  occur  after  the 
stage  of  redness,  about  the  second  or  the  third  day,  and  are  not  unlike  the 
blisters  following  a  burn.     Suppuration  may  occur  in  these. 

Phlegmonous  erysipelas  is  characterized  by  a  suppurative  process  in 
the  subcutaneous  connective  tissue,  coincident  with  the  inflammation  of  the 
skin.     It  constitutes  a  severe  form  of  the  disease. 

Gangrenous  Erysipelas. — All  the  other  forms  may  culminate  in  this, 
but  the  phlegmonous  variety  is  particularly  liable  to  merge  into  the  gangren- 
ous variety. 

Blisters  form  from  obliteration  of  the  nutritive  vessels,  and  bro^^^lish-red 
spots,  which  afterward  change  to  black,  appear.  Necrosis  of  tissue  and  putre- 
factive changes  soon  develop.  If  phlegmonous  cellulitis  has  not  preceded 
the  gangrenous  form,  it  rapidly  develops  after  the  appearance  of  this  form. 
The  gangrenous  condition  shows  the  same  tendency  to  spread  as  the  others. 

In  certain  erratic  or  wandering  forms,  the  disease  spreads  irrespective 
of  direct  continuity  of  tissue,  attacking  remote  portions  of  the  body  either 
simultaneously  or  successivel3^ 

Clinical  Course. — A  rapid  and  continuous  rise  of  temperature  occurs. 
13  177 


178  ACUTE    WOUND    DISEASES 

A  chill,  except  in  very  mild  cases,  usually  precedes  the  disease  development. 
Sweating  is  rare;   a  dry  condition  of  the  surface  is  present. 

Nausea  and  vomiting  generally  follow  the  chill.  Except  in  ver}'  scA'ere 
cases,  these,  as  well  as  the  chill,  are  not  repeated.  Anorexia  is  present.  Diar- 
rhea is  rare;  constipation  is  the  rule.  The  temperature  curve  is  irregular 
but  follows  more  or  less  the  progress  of  the  disease,  as  it  attacks  new  tissue. 
Its  duration  is,  on  an  average,  about  one  week.  Low  morning  temperature 
denotes  the  subsidence  of  the  attack.  High  temperature  both  morning  and 
evening  gives  a  more  favorable  prognosis  than  high  evening  temperature 
alone. 

Complications. — Albuminuria  to  a  moderate  extent  sometimes  occurs, 
though  it  soon  disappears.  Bronchitis  is  a  not  infrecjuent  complication,  but 
pneumonia  is  rare.  The  serous  membrane  may  be  attacked,  particularly 
the  meninges,  in  erysipelas  of  the  scalp.  Pleuritis  may  follow  er\'sipelas  of 
the  chest  walls^  peritonitis  that  of  the  abdominal  surface,  and  synovitis  er}'- 
sipelas  about  joints.  The  mucous  membranes  may  be  attacked,  with  sub- 
mucous infiltration,  particularly  the  nasal  and  faucial  cavities  in  erysipelas 
of  the  face. 

Etiology. — The  idiopathic  origin  of  erysipelas  has  long  been  disproved. 
''Catching  cold"  and  mental  emotion  are  no  longer  considered  factors  in  the 
causation  of  the  disease.  Erysipelas  is  infectious  in  origin,  contagious  in  char- 
acter, and  both  endemic  and  epidemic  in  its  occurrence.  It  is  most  frecjuent 
in  low,  swamjDy  localities,  less  so  in  elevated  and  dry  situations.  It  is  more 
prevalent  in  the  months  of  December,  February,  and  March. 

The  contagiousness  of  the  disease  was  known  long  prior  to  the  discovery 
of  the  bacterial  origin.  Instruments,  the  surgeon's  fingers,  bed  and  bedding 
were  known  to  convey  the  disease.  Micrococci  were  found  by  both 
H  u  e  t  e  r  and  Recklinghausen  in  blood  taken  from  eiysipelas 
patients  and  from  portions  of  skin  removed  postmortem,  but  it  was  not  until 
methods  of  obtaining  pure  cultures  were  introduced  that  ordinary  pus  cocci 
were  eliminated  and  the  essential  and  characteristic  organism,  the  Strepto- 
coccus pyogenes  (see  page  27),  was  isolated  and  demonstrated  (1884).  This 
demonstration  was  confirmed  by  successful  inoculation  experiments. 

Predisposition  to  Erysipelas. — This  varies,  as  in  all  infectious  diseases. 
It  ma}^  be  local  or  individual.  Certain  localities,  notably  the  scalp,  are  espe- 
cially predisposed  to  its  occurrence  (see  page  431).  Operations  for  the  re- 
moval of  lipomas  are  also  followed,  in  a  certain  proportion  of  cases,  by  ery- 
sipelas. The  fatty  tissue  itself  is  not  particularly  liable  to  it,  but  the  thin 
and  atrophic  skin  covering  lipomas  seems  to  invite  an  attack. 

The  predisposition  of  individuals  is  well  known.  It  is  more  freciuently 
observed  in  weak  persons  with  tender  skins.  For  this  reason  blonds  are  more 
liable  to  be  attacked  than  brunettes.  In  these,  slight  abrasions  of  the  epi- 
dermis, and  even  normal  furrows  of  the  skin,  as  well  as  the  open  mouths  of 
sebaceous  follicles,  may  be  the  seat  of  invasion  by  the  infectious  agent.  It 
is  very  doubtful  if  erysipelas  can  occur  without  invasion  of  the  streptococcus 
from  without. 

Except  for  the  endemic  occurrence  of  erysipelas,  careful  and  conscien- 
tious application  of  aseptic  precautions  will  prevent  its  development  as 
one  of  the  wound  seciuels.     Its  epidemic  occurrence  should  be  taken  into 


ERYSIPELOID  179 

account,  and.  in  its  presence,  operations,  particularly  about  the  head  and 
neck,  should  be  postponed. 

Erysipelas  occurring  in  patients  who  are  already  debilitated  from  large 
losses  of  blood  or  other  causes  follo^^'ing  major  operations  is  of  serious  import. 
This  is  particularly  true  of  the  suppurative  or  phlegmonous  form. 

In  certain  cases  of  inoperable  sarcoma  the  neoplasm  has  been  inoculated 
with  Streptococcus  pyogenes  (P  .  B  r  u  n  s  .  W  .  B  .  C  o  1  e  y)  .  While  en- 
couraging results  have  been  obtained  by  the  use  of  the  toxic  products  of 
Streptococcus  erj^sipelatis,  mixed  with  those  of  Bacillus  prodigiosus,  in  the 
hand.-?  of  the  originators  of  the  method,  the  latter  may  be  said  to  be  still  on 
trial.  C)n  the  other  hand,  death  has  followed  the  experiment  (J  a  n  i  c  k  e  , 
X  e  i  s  s  e  r)  . 

The  disease  known  as  elephantiasis  arabum  is  said  to  have  its  origin  in 
repeated  attacks  of  eiysipelas  (see  page  84). 

The  erratic  or  wandering  form  of  the  disease  fm-nishes,  as  a  rule,  a  better 
prognosis  than  the  other  varieties. 

Treatment. — In  the  prevention  of  the  cUsease  the  most  rigid  detaUs  of 
asepsis  are  requisite  (see  page  48;.  The  necessity  for  tliis  should  impress 
itself  on  the  surgeon's  mind,  particularly  if  he  is  compelled  to  dress  non- 
infected  wounds  after  bemg  m  contact  with  a  patient  who  has  er\'sipelas.  All 
dressings  that  have  been  used  should  be  burned,  and  towels,  sheets,  blankets, 
etc..  subjected  to  at  least  the  boUing  process  in  the  laimdr\'.  Instnmients 
should  undergo  the  most  rigid  sterilization,  and  the  free  and  liberal  use  of  soap, 
hot  water,  and  subhmate  or  carbolic  solution  on  the  part  of  the  attendants 
should  be  enforced. 

Prior  to  the  introduction  of  antiseptics  into  practice,  the  surgeon  was 
almost  helpless  in  the  face  of  this  formidable  disease.  Its  rational  treatment 
began  ^^ith  L  ii  c  k  e '  s  recommendation  of  the  local  use  of  turpentin 
and  H  u  e  t  e  r  '  s  use  of  tar  and  of  the  subcutaneous  mjection  of  carboKc 
acid  at  the  marghi  of  the  disease,  at  wliich  point  the  streptococci  proliferate 
most  rapidly.  The  carbolic  injections  may  be  replaced  by  sublimate  1  :  5000, 
or  salicylic  acid  solutions  (Peterson).  Multiple  scarifications  and  incisions 
through  the  skin  at  the  margin  of  the  er^'sipelatous  zone  (K  r  a  s  k  e  ,  R  i  e  d  e  1), 
with  the  subsequent  use  of  a  5  per  cent  carbolic  or  a  1  :  1000  sublimate 
solution  (L  a  u  e  n  s  t  e  i  n)  m  the  shape  of  compresses,  are  valuable  measiu'es. 
The  addition  of  tmcture  of  opiimi  in  the  proportion  of  two  oimces  to  the 
pint  to  the  antiseptic  solution  is  of  advantage.  These  solutions  should  be 
applied  warm  upon  compresses  either  with  or  T\-ithout  the  lorelimhiari' 
incision  of  the  skin,  and  the  compresses  covered  with  oiled  silk.  Where  danger 
is  to  be  apprehended  from  carboHc  acid  poisoning  creolin  may  be  substituted. 

^  The  fever  should  be  combated  by  the  usual  antip^Tetic  measures.  Luke- 
warm baths  and  the  cold  pack  may  be  necessary-  in  extremely  high  tempera- 
tinges;  quuiin  is  useful  in  ordinary'  cases.  Supporting  meastires  should  be 
employed  and  nourishing  but  easily  digested  food  allowed. 

ERYSIPELOID 

Rosen  bach  has  described,  mider  this  name,  a  form  of  infectious  derma- 
titis which  is  sometimes  obser\^ed  in  persons,  butchers,  cooks,  etc..  who  have 
occasion  to  handle   dead  animals.      The  point   of  primary'  infection  is  some 


180  ACUTE   WOUND    DISEASES 

minute  abrasion  of  the  epidermis,  from  which  point  a  bhiish-red  infiltration 
gradually  spreads,  generally  toward  the  trunk.  The  infection  travels  very 
slowty,  occupying  a  week  in  passing  from  the  finger-tip  to  the  metacarpopha- 
langeal joint.  The  margin  of  the  patch  maintains  the  original  liluish-red 
infiltration  appearance,  while  the  point  originally  infected  and  its  immediate 
surroundings  return  to  the  normal. 

There  are  no  constitutional  disturbances;  the  disease  is  a  purely  local 
affair  and  has  a  self-limited  course,  lasting  two  or  three  weeks.  The  inflamed 
parts  give  rise  to  some  burning,  smarting  sensations.  The  disease  is  of  interest 
to  the  surgeon  mainly  because  of  the  liabihty  to  mistake  it  for  erysipelas. 

The  etiologic  factor  in  the  disease  is  some  specific  infecting  agent,  supposed 
to  be  one  of  the  thread-forming  microbes. 

No  treatment  is  necessary.     The  disease  tends  intrinsically  to  recovery. 

HOSPITAL  GANGRENE 

This  consists  of  a  septic  inflammation  of  the  granulating  surface  of  wounds 
in  which  there  is  a  coagulative  necrosis  of  the  upper  layer  of  the  granulations, 
due  to  either  an  imperfect  development  of  the  vessels  or  an  obstruction  of 
their  lumina  by  septic  inflammatory  processes,  or  a  coagulation  of  fibrin  in 
a  layer  of  exuded  blood-plasma.  The  resulting  pellicle  occurs  in  the  shape 
of  a  firmly  adherent  thin  parchment-like  layer  resembling  diphtheritic  deposits 
on  mucous  membranes  ("wound  diphtheria,"  Hueter).  The  dis- 
ease begins  with  small  pointlike  ecchymoses  in  the  granulations;  the  latter 
turn  to  a  dirty  grayish-brown  color.  Fusion  of  the  granulations  occurs,  minute 
abscesses  form,  and  a  true  ulcerative  process  may  be  initiated.  In  the  pulpy 
variety  a  profuse  exudation  occurs  from  the  newly  formed  blood-vessels  in 
the  granulations.  The  latter  become  greatly  swollen  and  grayish-white,  ris- 
ing above  the  level  of  the  skin  like  a  mass  of  sponge.  Finally  these  may  cul- 
minate in  the  gangrenous  form..  The  inflamed  structures  become  necrotic, 
putrefaction  sets  in,  and  sometimes  the  most  rapid  advance  of  the  disease  takes 
place.  The  destruction  of  the  granulations  opens  up  the  way  for  renewed 
infection  and  the  rapid  breaking  down  of  the  tissues  furnishes  the  bacterial 
agents  of  infection  in  large  numbers. 

Clinical  Course. — All  of  these  forms  may  be  observed  on  the  same 
granulating  surface.  Slight  hemorrhages  may  be  present  at  one  point,  sup- 
purative destruction  of  the  granulations  at  another,  and  a  spongy  elevation 
may  appear  at  a  third.  Finally  a  gangrenous  condition  may  supervene.  As 
long  as  the  granulations  remain  intact  no  lymph-vessels  are  opened,  and  con- 
stitutional symptoms  are  absent.  With  the  destruction  of  the  granulations, 
bacterial  infection  occurs  and  febrile  symptoms  appear.  This  may  occur 
within  the  first  twenty-four  hours.  The  rise  of  temperature,  although  not 
high,  is  accompanied  by  a  disproportionate  depression  of  the  vital  powers. 
In  this  respect  the  disease  resembles  diphtheria  of  mucous  membrane.  The 
temperature,  even  in  markedly  septic  and  gravely  depressed  conditions,  may 
remain  normal  or  even  become  subnormal. 

Prognosis. — This  is  grave  in  proportion  to  the  amount  of  depression 
and  the  extent  of  the  local  disturbances.  In  the  gangrenous  variety  large 
vessels  may  be  opened  and  fatal  hemorrhage  follow.     Invasion    of    large 


MALIGNANT    EDEMA;     ACUTE    PURULENT   EDEMA  181 

serous  cavities  or  of  joints  by  tli(>  ulceration  or  gangrenous  process  involves 
great  danger  to  life.     I\ycniia  may  develop. 

Etiology. — The  affection  arises  from  infection  of  the  granulating  sur- 
face, either  from  contact  with  unclean  dressings  or  from  the  air.  In  former 
times  the  disease  occurred  especially  in  military  hospitals,  from  want  of  care 
in  the  selection  and  application  of  dressings;  hence  it  was  known  as  hospital 
gangrene.  It  occurs,  however,  in  private  as  well  as  in  hospital  practice,  if 
care  is  not  exercised  in  wound  dressing.  The  mass  of  microorganisms  found 
locally  and  in  the  blood  of  the  patient  fixes  the  bacterial  origin  of  the  disease ; 
a  specific  germ,  however,  has  not  yet  been  discovered.  It  is  probable  that 
the  gangrene  which  occurs  in  wounds  may  be  caused  by  more  than  one  micro- 
organism. In  two  instances  of  rapid  gangrene  occurring  in  my  service  in  St. 
Mary's  Hospital,  Bacillus  pyocyaneus  was  isolated  in  pure  culture  from 
tissues  at  some  distance  from  the  gangrenous  area. 

Treatment. — This  is  to  be  conducted  on  the  principles  of  asepsis  and 
antisepsis,  the  former  method  to  be  used  in  the  prevention,  the  latter  in  the 
cure.  The  use  of  carbolic  moist  compresses  is  indicated;  these  are  to  be 
renewed  at  least  as  often  as  once  in  six  hours.  A  5  per  cent  solution  should 
be  employed.  At  each  change  of  dressing  the  softened  granulations  should 
be  curetted  away.  In  more  severe  cases  an  application  of  zinc  chlorid,  from 
10  to  20  per  cent  in  strength,  is  to  be  used,  well  rubbed  in.  In  the  gangrenous 
variety  recourse  should  be  had  to  the  thermocautery  for  the  purpose  of  com- 
pletely destroying  the  infected  surface  and  its  infectious  agents.  The  effect 
of  the  application  of  the  actual  cautery  to  these  gangrenous  conditions  of  a 
wound  is  sometimes  marvelous.  Acid  escharotics  (chromic  acid,  nitric  acid, 
etc.)  are  to  be  preferred  to  alkaline  ones,  such  as  caustic  potash,  etc.,  for  the 
reason  that  the  former  have  a  more  decidedly  antibacterial  effect.  Hydrogen 
dioxid  is  useful  in  aiding  the  destruction  of  the  dead  organic  matter  (W  a  r  - 
r  e  n) .  Iodoform  gauze  saturated  with  hydrogen  dioxid  should  be  packed 
in  all  the  recesses  of  the  wound. 

MALIGNANT  EDEMA    (Pirogoff);    ACUTE  PURULENT  EDEMA 

This  form  of  gangrenous  inflammation,  sometimes  kno^^Ti  as  gangrene 
foudroyante  (M  a  i  s  o  n  n  e  u  v  e),  is  a  most  dangerous  affection.  It  some- 
times accompanies  severe  injuries  of  bone  and  extensive  contusions  of  soft 
parts,  as  well  as  less  severe  injuries,  insect  stings,  etc.  It  is  characterized  by 
rapidly  advancing  septic  inflammation  of  the  subcutaneous  connective  tissue 
and  the  intermuscular  planes,  with  rapid  putrid  decomposition  and  the  for- 
mation of  gases.  The  skin  assumes  a  dirty  brownish-red  color,  with  distended 
veins  filled  with  stagnating  blood.  The  tissues  are  edematous  and  infiltrated 
with  gases,  which  give  rise  to  a  crackling  sensation  on  palpation.  A  thin 
ichorous  discharge  occurs  from  the  wound ;  this  can  also  be  pressed  out  of  the 
edematous  tissues  into  the  wound  cavity.  The  neighboring  lymphatic  glands 
become  greatly  swollen,  and  the  general  condition  of  the  patient  shows  that 
the  products  of  putrefaction  are  being  rapidly  disseminated  through  the  sys- 
tem by  the  medium  of  the  lymph-channels.  The  temperature  rises  rapidly; 
remission,  as  a  rule,  does  not  occur.  Typhoid  symptoms,  such  as  blunted 
sensorium,  dry  tongue,  tough,  fetid  mucus  in  the  roof  of  the  mouth,  rapid 
and  feeble  pulse,  and  dilated  pupils  are  present.     In  other  cases  jactitation 


182  ACUTE    WOUND    DISEASES 

and  delirium,  followed  by  coma  and  involuntary  evacuation  of  the  contents 
of  the  bladder  and  rectum,  precede  the  fatal  issue.  The  patient  is  too  apath- 
etic to  complain  of  either  pain  or  thirst.  The  sj'-mptoms  may  supervene  within 
a  few  hours  of  the  injury,  and  death  may  occur  in  from  fort3'-eight  hours  to 
three  or  four  days,  an  entire  extremity  in  the  meanwhile  becoming  involved 
in  the  disease. 

Etiology. — The  affection  is  essentially  the  result  of  a  putrefactive,  process 
and  is  of  undoubted  bacterial  origin.  It  probably  depends  on  a  bacillus 
found  almost  universally  in  common  garden  earth.  Bacillus  oedematis 
maligni  (see  page  30). 

Treatment. — Since  the  introduction  of  antiseptic  methods  of  treatment 
this  excessively  dangerous  disease  is  of  much  less  frec^uency  than  hereto- 
fore. A  most  vigorous  antiseptic  course  must  be  followed.  While  the  use 
of  free  and  extensive  incisions  may  be  of  some  service  in  mild  cases,  these  cases 
are  so  few  compared  with  those  overwhelmingly  malignant,  that  amputation 
will  be  the  rule,  rather  than  the  exception.  This  should  be  performed  promptly, 
and  as  high  up  as  possible. 

INFECTIOUS  EMPHYSEMA 

This  is  an  emphysematous  condition  of  the  tissues  of  the  body  and  is  due 
to  the  presence  of  Bacillus  aerogenes  capsulatus.  The  microorganisms 
may  gain  entrance  through  an  accidental  or  an  operation  wound  and  infect 
the  surrounding  structures.  Their  presence  is  followed  by  the  formation  of 
gas,  which  is  marked  by  the  occurrence  of  swelling  and  a  crackling  sensation 
on  palpation.  In  this  class  of  cases  there  is  usually  but  moderate  con- 
stitutional disturbance.  In  more  severe  cases  the  viscera  are  filled  ^^^lth  gas 
bullae  and  the  blood  T\'ith  bubbles.  In  these  cases  it  is  supposed  that  the 
infection  gains  entrance  from  a  perforative  lesion  of  the  intestinal  canal. 

Treatment. — ^^^len  the  emphysema  appears  in  the  neighborhood  of  a 
wound  the  latter  is  to  be  considered  as  the  starting-point  of  the  infection  and 
treated  accordingly.  In  mild  cases  when  the  emphysematous  condition  is 
limited  and  shows  no  disposition  to  spread,  and  when  constitutional  symp- 
toms are  absent,  simple  watching  is  all  that  is  required.  Upon  the  super- 
vention of  symptoms  of  extension,  or  of  constitutional  disturbance,  however, 
the  treatment  for  an  infected  wound  is  to  be  instituted  immediately.  If  the 
emphysema  still  persists  or  increases,  in  addition  to  thorough  disinfection  of 
the  wound,  incisions  are  to  be  made  in  the  infected  area  and  wet  sublimate 
gauze  is  to  be  employed  as  a  packing,  compresses  of  this  being  applied 
as  well.  The  milcl  cases  may  recover  without  the  reopening  of  the  wound, 
and  even  the  more  severe  forms,  with  simple  yet  efficient  antiseptic  treat- 
ment of  the  wound. 

SEPTICEMIA 

This  is  a  form  of  systemic  poisoning  of  bacterial  origin  in  which  living 
bacteria  are  found  in  the  blood.  While  they  are  deposited  in  many  cases 
in  the  liver,  spleen,  and  kidneys,  the  disease  differs,  in  typic  examples,  from 
pyemia,  in  that  septic  inflammation  and  the  formation  of  abscesses  in  these 
organs  do  not  occur.  When  the  symptoms  of  sepsis  as  well  as  those  of  pye- 
mia are  present  the  term  septicopyemia  is  used. 


SEPTICEMIA  183 

Clinical  Course. — The  disease  is  ushered  in  by  a  rise  of  temperature, 
this  varyins:  from  101°  to  105°  F.  even  within  the  first  few  days  after  the 
mjiirv.  The  occurrence  of  a  well-marked  chill  is  not  common  and  is  not  re- 
peated if  it  does  occur,  the  disease  differing  in  this  respect  from  pyemia.  The 
pulse-rate  is  increased  to  120  or  more,  and  a  remarkable  condition  of  indifference 
and  lassitude  is  present.  The  tongue  is  dry  and  leather-like  and  is  protruded 
^\•ith  a  hesitating  and  trembling  movement  over  the  parched  lips.  The  skin 
is  hot  and  dry,  and  is  a  dirty  brownish  color.  In  severe  cases  a  pale  yel- 
lowish hue  of  the  skin  is  present,  with  dark  purplish- red  spots  (petechiae). 
These  point  to  a  disintegration  of  the  blood;  the  blood-corpuscles  perish  and 
the  blood  pigment  is  diffused  into  the  tissue  (hematogenous  icterus).  The 
walls  of  the  vessels  also  undergo  changes  from  the  influences  of  the  ptomains, 
and  a  hemorrhagic  predisposition  is  present.  The  wound  itself  undergoes 
characteristic  changes.  The  edges  become  shmnken,  the  granulations  become 
flabbv  and  turn  to  a  dirty  gray,  and  thin  and  offensive  discharge  occurs. 
Anorexia  is  present;  constipation  is  the  rule,  though  in  the  severe  forms 
profuse  and  not  infrequently  bloody  diarrheic  discharges  occur.  The  respi- 
rations are  rapid  and  superficial. 

The  disease  may  last  from  five  to  fourteen  days.  Improvement  is  an- 
nounced by  remissions  of  the  fever,  preceded  by  a  more  or  less  pronounced 
perspiration,  the  clearmg  up  of  the  intellect  and  deeper  and  less  rapid  respira- 
tions. The  wound  assumes  a  healthier  aspect  and  granulations  spring  up. 
In  fatal  cases  the  apathetic  state  passes  into  coma,  the  temperature  may  drop 
below  the  normal,  and  the  pulse  becomes  extremely  rapid  and  feeble. 

Pathologic  Anatomy. — Examination  of  the  blood  shows  the  destruc- 
tive effects  of  the  bacterial  infection  on  its  corpuscular  elements.  The  con- 
tents of  the  large  venous  trunks  show  incomplete  coagulation;  the  blood  is 
very  dark,  and  tarlike.     An  acid  reaction  is  sometimes  observed. 

The  spleen,  liver,  and  kidneys  are  the  seat  of  more  or  less  turgescence. 
The  serous  membranes  are  sometimes  more  or  less  covered  with  ecchymoses 
and  the  cavities  contain  a  small  amount  of  brownish-red  fluid.  The  fibrillae 
of  the  muscles  are  the  subject  of  granular  degeneration,  as  shoT^^l  b}^  micro- 
scopic examination.  They  are  a  dark-brown  color,  particularly  in  the  neigh- 
borhood of  the  wound.  The  condition  of  the  blood  is  such  as  to  produce  rapid 
decomposition  of  the  body  after  death. 

Etiology. — The  disease  was  formerly  regarded  as  autointoxication  from 
the  absorption  of  the  products  of  a  general  proliferative  process  occurrmg  in 
the  wound.  Attempts  were  made  to  isolate  a  chemic  substance  from  the 
wound  secretion  (sepsin  of  Bergmann).  Inoculation  experiments  with 
this,  though  fatal  to  the  animals,  did  not  reproduce  the  picture  of  the 
disease. 

Klebs,  m  1871,  demonstrated  the  presence  of  bacteria  m  septic 
wounds.  By  filtration  of  1  he  wound-secretion  he  also  showed  that  the  filtered 
liquid  had  but  a  comparatively  slight  degree  of  infecting  power,  wliile  the 
filtrate  itself  produced  a  rapiclly  fatal  febrile  condition,  thus  proxdng  that 
the  disease  was  one  of  infection  rather  than  of  intoxication.  The  experi- 
ments of  Devalue  (1872),  however,  settled  the  question.  Inoculations 
from  one  animal  to  another  showed  that  even  the  tenth  animal  died  from 
septicemia. 


184  ACUTE    WOUND    DISEASES 

The  question  as  to  the  bacterial  origin  of  septicemia  was  further  studied 
by  C .  H  u  e  t  e  r  ,  whose  results,  however,  were  subjected  to  considerable 
criticism,  though  he  undoubtedly  discovered  the  presence  of  bacteria  in 
septicemic  animals  as  well  as  in  man.  His  observations  were  confirmed  in 
part  by  Birch-Hirschfeld  and  Koch. 

While  certain  microorganisms  are  found  pathogenic  to  different  classes 
of  animals  (bacillus  of  mouse  septicemia  of  Koch,  bacillus  of  hog 
cholera  of  Salmon  and  Smith,  the  micrococcus  of  rabbit  septicemia, 
etc.),  a  separate  form  has  not  yet  been  discovered  in  man. 

Prognosis. — Prior  to  the  antiseptic  era,  this  disease  was  preeminently 
a  fatal  one.  Together  with  pyemic  and  hospital  gangrene,  it  swept  away  the 
great  majority  of  patients  who  died  in  the  surgical  wards  of  hospitals.  At 
the  present  time  these  three  diseases  are  rarely  observed,  and  only  then  when 
there  has  been  a  neglect  to  apply,  or  a  failure  to  maintain  the  necessary  asep- 
tic or  antiseptic  measures. 

Treatment. — In  the  very  beginning  of  the  disease,  the  changed  condi- 
tions of  the  wound  and  the  occurrence  of  a  foul  odor  will  arouse  suspicion, 
and  an  energetic  application  of  antiseptic  treatment  will  be  imperatively  de- 
manded. This  includes  the  opening  up  of  the  wound,  the  curetting  away  of 
decomposing  shreds  of  sloughing  connective  tissue,  thorough  irrigation,  and 
the  establishment  of  counter-openings  when  necessary  for  purposes  of  efficient 
drainage.  The  interior  of  the  wound  should  be  well  swabbed  with  a  10  per 
cent  solution  of  zinc  chlorid.  When  a  joint  is  involved,  the  medullary  tissue 
is  finally  invaded,  and  resection  or  amputation  may  have  to  be  resorted  to  in 
order  to  save  life.  The  internal  treatment  will  include  the  use  of  quinin  and 
alcoholic  stimulants.  Oil  of  turpentin  has  likewise  been  recommended. 
The  inhalation  of  oxygen  with  the  view  of  utilizing  to  the  greatest  extent  the 
function  of  the  red  blood-corpuscles  still  available  is  indicated. 

PYEMIA 

This  is  an  infectious  wound  disease  produced  by  pyogenic  organisms  and 
characterized  in  its  course  by  the  invasion  of  distant  tissues  of  the  body 
by  secondary  foci  of  suppuration.  The  microorganisms  are  carried  into  the 
blood  through  the  lymph-channels  (H  a  1  b  a  n),  whence  they  are  distrib- 
uted to  the  points  where  they  lodge  and  proliferate  and  set  up  destructive 
changes. 

Isolated  cases  are  observed  in  which  a  so-called  spontaneous  pyemia  (cryp- 
togenic pyemia)  occurs.  These  either  occur  from  the  passage  of  bactei'ia  through 
the  medium  of  the  follicles  of  the  mucous  membrane  lining  the  respiratory 
or  digestive  tract,  or  depend  on  a  minute  abrasion  of  the  epidermis,  without 
the  development  of  a  distinct  local  inflammation. 

Finally,  a  mixed  infection  may  occur,  the  so-called  septicopyemia.  Either 
condition  may  precede  the  other,  but  the'  term  should  not  be  used  to  apply 
to  a  distinct  affection,  for  such  does  not  exist. 

Metastases. — These  are  found  most  frequently  in  the  lungs.  Abscesses 
of  various  sizes  are  found,  usually  situated  at  the  periphery.  When  adjacent 
to  the  pleural  covering,  a  pleuritis  occurs,  which  may  result  in  serous,  fibrin- 
ous, seropurulent,  or  even  purely  suppurative  exudation.  A  diffused  lobar 
pneumonic  infiltration  may  take  the  place  of  the  multiple  foci  and  inclose  a 
single  metastatic  abscess,  or  a  gangrenous  portion  of  the  lung. 


PYEMIA  185 

Next  in  frequency  the  liver,  kidneys,  and  spleen  are  the  seat  of  pyemic 
suppurative  foci.  The  connective  tissue  and  muscles,  particularly  the  ten- 
dinous attachnionts  of  the  latter,  as  well  as  the  heart,  brain,  eyes,  the  syn- 
ovial lining  of  joints,  and  the  serous  membranes  are  attacked.  Tlie  knee-joint, 
hip- joint,  and  elbow-joint  are  the  most  frecjuently  attacked.  These  may  be 
simultaneously  or  successively  invaded,  and  without  due  care  the  joint  affec- 
tion may  be  mistaken  for  a  rheumatic  attack.  The  serous  membrane  may 
be  attacked  independently  of  neighboring  structures  or  adjacent  organs,  as, 
for  instance,  tendinous  sheaths,  or  these  structures  may  suffer  from  extension, 
as  the  peritoneum  in  case  of  the  liver  and  spleen,  the  pericardium  in  the  case 
of  the  heart,  the  arachnoid  in  case  of  the  brain,  etc. 

Clinical  Course. — Usually  several  days  elapse  between  the  reception 
of  the  injury  and  the  occurrence  of  the  primary  suppuration.  The  onset  of 
the  disease  proper  occurs  several  days  later.  From  the  date  of  the  injury 
to  the  commencement  of  the  pyemic  process,  therefore,  the  earliest  symp- 
toms will  not  occur  within  eight  days,  and  they  may  be  delayed  for  several 
weeks.  The  occurrence  of  metastases  will  be  marked  by  a  sharp  chill,  followed 
by  a  rise  of  temperature  and  local  symptoms  to  indicate  the  points  of  secondary 
suppurative  foci.  The  temperature,  though  it  may  reach  105°  F.,  does  not 
rise  rapidly.  The  extent  of  the  fever  due  to  metastases  may  be  masked  by 
the  previous  existence  of  a  surgical  septic  fever,  or  erysipelas.  The  occurrence 
of  repeated  chills  and  the  increase  of  previously  existing  fever,  which  may 
assume  a  remittent  or  even  intermittent  type,  will  serve  to  identify  the  process 
when  occurring  in  conjunction  with  local  symptoms,  such  as  cough  with 
physical  signs  of  circumscribed  infiltration  and  softening,  in  case  the  lungs 
are  invaded;  local  pain  and  tenderness  in  the  case  of  the  liver  and  spleen; 
pus  in  the  urine  in  the  case  of  the  kidneys,  etc.  The  disease  is  most  likely 
to  be  mistaken  for  a  severe  malarial  affection ;  the  sweating  stage  of  the  latter, 
however,  is  absent.  The  chills  may  occur  coincidentally  with  each  new  deposit, 
and  in  the  commencement  of  the  disease  each  succeeding  suppurative  focus 
furnishes  a  more  or  less  distinct  exacerbation  of  the  febrile  symptoms.  With 
the  occurrence  of  a  large  number  of  metastases  the  chills  become  less  frequent, 
the  fever  maintains  itself  at  a  higher  grade,  the  vital  forces  give  way,  and  the 
patient  sinks  from  extreme  and  rapid  asthenia. 

:\lany  of  the  points  of  deposit  may  escape  discovery  altogether,  particularly 
when  in  deep-seated  joints,  as  the  hip.  This  is  due  in  some  degree  to  the 
painless  character  of  the  suppurative  process  of  the  joints  in  this  affection  as 
compared  with  the  process  which  occurs  in  traumatic  cases. 

The  other  constitutional  symptoms  are  such  as  obtain  generally  in  febrile 
affections,  including  dry  skin,  the  latter  assuming  a_  leathery  character  in 
cases  of  long  duration,  dry  tongue,  and  vexatious  thirst. 

Etiology.— Clinical  observations  point  to  the  probability  of  a  specific 
microorganism  for  this  disease,  yet  efforts  thus  far  have  failed  to  isolate  such. 
If  the  bacteria  of  common  suppuration  were  alone  involved  in  the  causation, 
the  disease,  it  is  fair  to  assume,  would  be  of  far  greater  frequency.  It  has 
been  asserted  that  an  essential  factor  in  the  production  of  the  disease  is  the 
absence  of  a  protecting  wall  of  granulation  in  primary  suppurative  foci,  throm- 
bophlebitis resulting.  Even  this  will  not  explain  its  infrequency;  such  gran- 
ulation barriers  must  be  very  often  absent,  as,  for  instance,  in  whitlow  and  its 


186  ACUTE    WOUND    DISEASES 

fi-eqiient  sequel,  phlegmonous  inflammation  of  the  synovial  sheaths  of  ten- 
dons. Yet  even  in  preantiseptic  times  pyemia  rarely  followed  these  rather 
common  conditions.  That  some  specific  morbific  cause  enters  from  without 
is  rendered  probable  by  the  fact  that  the  disease  is  of  rather  frequent 
occurrence  in  improperly  treated  and  hence  suppurating  compound 
fractures,  while  in  acute  infectious  osteomyelitis  it  is  exceedingly  rare.  In 
both  instances  there  is  an  acute  suppurative  inflammation  and  the  medullary 
veins  are  equally  exposed  to  the  invasion  of  bacterial  infection. 

The  epidemic  and  endemic  occurrence  of  the  disease  is  to  be  taken  into 
consideration  in  discussing  its  etiology.  Its  outbreaks  in  connection  with 
crowded  militar}'  hospitals  in  times  of  war  are  matters  of  medical  history. 
There  are  many  reasons  for  believing  that  there  is  a  specific  poison  at  work 
under  these  circumstances,  and  that  this  is  capable  of  being  conveyed  by  the 
air  as  well  as  by  contact.  It  was  suggested  by  H  u  e  t  e  r  that  this 
poison  resides  in  a  special  microorganism  which  possesses  peculiarly  ener- 
getic powers  of  infection,  but  which,  in  its  turn,  is  destroyed  by  the  common 
pus  cocci.  R  o  s  e  n  b  a  c  h  ,  however,  concluded  after  patient  observation 
that  Streptococcus  pyogenes  and  Staphylococcus  pyogenes  aureus  produced 
pyemia. 

The  metastases  are  accomplished  through  the  medium  of  the  blood-cur- 
rent, as  well  as  through  that  of  the  blood-lymph.  When  the  route  is  the 
blood,  the  lungs  suffer  mainly.  The  metastases,  under  these  circumstances, 
are  largely  of  embolic  origin  (V  i  r  c  h  o  w)  .  These  emboli  are  infected 
with  bacteria  and  again  produce  suppuration  at  the  place  of  deposit.  The 
loosening  of  a  portion  of  clot  and  its  migration  to  the  right  heart,  and  thence 
by  way  of  the  pulmonary  artery  to  the  respective  lung,  in  case  no  bacterial 
infection  or  pus  is  likewise  transferred,  will  produce  simply  a  hemorrhagic 
infarction. 

Pyeinic  foci  occur  in  the  liver,  kidney,  spleen,  muscles,  and  subcutaneous 
connective  tissue;  in  fact,  the  entire  capillary  area  is  exposed  to  infection. 
Bacteria  alone,  or  carried  along  by  pus-corpuscles,  traverse  the  lymph-ves- 
sels and  glands,  and  may  pass  even  through  the  pulmonary  circulation  and 
thus  gain  access  to  the  arterial  current.  In  this  manner  the  general  invasion 
of  joints,  pleura,  pericardium,  and  peritoneum  is  explained. 

Prognosis. — The  disease  once  under  way,  its  cure  depends  on  an 
arrest  of  the  metastases,  and  the  subsequent  discharge,  resorption,  or  encap- 
sulation of  already  existing  secondary  foci.  A  pulmonary  abscess  may  dis- 
charge into  a  bronchus;  nephritic  abscess  may  empty  itself  into  the  pelvis  of 
the  kidney  and  be  discharged  with  the  urine;  those  situated  near  the  surface 
may  make  their  way  through  the  skin.  The  joint  affections  do  not  always 
suppurate,  and  hence  resolution  may  likewise  occur.  Notwithstanding  all 
these  possibilities,  recovery  from  the  disease  is  rare;  the  affection  always 
tends  to  a  fatal  termination. 

In  proportion  as  the  primary  focus  of  suppuration  is  small  and  easily  ac- 
cessible, permitting  surgical  treatment,  will  the  prognosis  be  rendered  more 
favorable.  The  ability  of  the  patient  to  bear  repeated  deposits  and  renewed 
assaults  upon  his  vital  forces  will  also  have  a  bearing  on  the  prognosis.  A 
condition  of  "  chronic  pyemia  "  may  finally  carr}-  the  patient  off  after  a  long 
and  painful  struggle. 


TETANUS 


187 


Treatment.— Under  careful  aseptic  and  antiseptic  management  of  wounds 
this  (list>asc>  luis  almost  disappeared.  Yet  it  is  occasionally  met  with,  under 
circumstances  beyond  the  control  of  the  surgeon.  The  primary  focus  of  sup- 
puration must  be  at  once  attacked,  in  order  to  prevent  further  mfection. 
Free  incisions  and  vigorous  antiseptic  treatment  may  suffice  m  mild  cases. 
These  failing  if  the  suppuration  is  in  a  limb  and  important  mternal  organs 
are  not  in^•otved,  amputation  must  be  performed;  extirpation  of  a  suppuratnig 
tumor,  and  extensive  incision  of  phlegmonous  areas,  are  measures  not  to  be 
considered  as  too  radical  when  life  is  so  urgently  threatened. 

Lio-ation  of  the  larger  veins,  when  these  are  found  to  l)e  the  seat  of  thrombi, 
has  been   suggested    (Klebs)  ;    favorable   results    of  this  expedient  have 

been  reported.  i      i  i  u 

When  the  joints  involved  show  evidences  of  suppuration,  they  should  be 
freelv  incised,  antiseptically  irrigated,  and  drained.  Abscesses  in  the  mus- 
cular structures  and  in  the  parotid  gland,  which  seems  particularly  liable  to  the 
infection,  as  well  as  those  in  the  connective  tissue,  may  be  easily  reached  and 
freely  incised.  The  pericardium  may  be  aspirated  (B.  F.  W  e  s  t  b  r  o  o  k)  , 
and  even  incised  and  drained;  the  pleural  cavity  is  capable  of  free  drainage 
and  antiseptic  irrigation;   the  peritoneum  may  be  incised  and  drained. 

In  the  meanwhile  the  patient's  strength  must  be  supported  by  every 
possible  means,  both  dietetic  and  medicinal.  Quinin,  or  the  cinchona  prep- 
arations with  mineral  acids,  are  useful.  Alcoholic  stimulants  and  malt  liquors 
are  particularlv  indicated.  Antipyretics  of  coal-tar  origin,  such  as  antipyrm, 
antifebrin,  and  phenacetin,  should  be  used  cautiously,  if  at  all,  on  account 
of  their  depressing  action. 

TETANUS 

This  belongs   to   the   class   of   wound   infectious    diseases   in   which    the 

microbes  or  their  ptomains  affect  the  central  nervous  system.    It  is  characterized 

clinically  by  spasm,  either  clonic  or  tonic,  of  definite  muscular  groups,     ihose 

of  mastication  (trismus)  and  of  the  head  and  back  (opisthotonos)  are  the  most 

frequentlv  affected.  •  t.  +i 

Clinical  Course.— The  disease  usually  commences  with  some  restless- 
ness on  the  part  of  the  patient,  and  an  anxious  or  pinched  expression  of  coun- 
tenance, with  elevation  of  the  external  angle  of  the  eyes.  There  is  some  diffi- 
cultv  in  opening  the  mouth.  In  speaking,  the  patient  keeps  the  teeth  to- 
gether on  account  of  the  spasm  of  the  masseteric  and  temporal  muscles.  Ihe 
muscles  of  deglutition  next  become  affected,  and  finally  the  muscles  of  the 
back  of  the  neck  and  the  extensors  of  the  spine.  The  opisthotonos  which  now 
occurs  is  characteristic;  the  body  rests  on  the  occiput  and  heels  when  the 
patient  is  in  the  dorsal  position.  The  anterior  trunk  muscles  may  become 
affected,  producing  a  position  the  reverse  of  opisthotonos,  that  of  emprosthot- 
onos  Contraction  of  the  lateral  trunk  muscles  produces  pleurothotonos 
More  or  less  rigidity  of  the  affected  groups  of  muscles  persists  (tonic  spasm  , 
though  this  is  increased  bv  paroxvsmal  convulsive  movements  (clonic  spasm;. 
The  svmptoms  bear  a  striking  resemblance  to  those  of  strychnm  poisoning. 

The  slightest  peripheral  irritation,  even  a  draft  of  cold  air,  m  severe  cases, 
brings  on  aggravation  of  the  muscular  spasm  and  most  excruciatmg  pam 
Respiration  is  interfered  Anth  in  proportion  to  the  extent  of  mvolvement  ot 


188  ACUTE   WOUXD    DISEASES 

the  respiratory  muscles.  The  pains,  which  are  sometimes  most  excruciatingly 
severe,  usually  follow  the  course  of  the  nerves  leading  from  the  spinal  cord 
to  the  affected  muscles.  The  sensorium  generally  remains  unaffected  during 
the  entire  course  of  the  disease.  A  profuse  salivary  secretion  escapes  from 
the  mouth  through  the  set  teeth.  The  pulse  in  acute  cases  is  rapid  and  feeble, 
and  the  temperature  rises  to  40°  or  41°  C.  (104°  to  106°  F.).  W  under- 
lich  has  noted  a  postmortem  temperature  of  44.7°  C.  (112°  F.).  Pro- 
fuse sweating  is  a  characteristic  symptom. 

There  is  inability  to  take  food  and  drink.  In  consecjuence  of  this,  and  of 
the  intense  pain  and  loss  of  sleep,  there  is  rapid  emaciation  and  loss  of  strength 
early  in  the  disease.  There  is  generally  more  or  less  cyanosis  present,  and, 
the  diaphragm  becoming  involved,  a  spasm  of  this  suddenly  produces  death. 
When  death  takes  place  from  exhaustion,  a  profuse  and  clammy  perspiration, 
coldness  of  the  extremities,  and  weak,  intermittent,  and  rapid  pulse  precede 
the  lethal  exit,  which  may  occur  in  some  cases  in  a  few  days. 

In  cases  which  terminate  in  recovery,  the  muscles  of  mastication  present 
m^ore  or  less  stiffness  for  several  weeks,  which  gradually  subsides. 

Tetanus  neonatorum. — This  occurs  in  infants  during  the  first  week  fol- 
lowing birth.  It  is  almost  invariably  fatal,  and  that  very  shortly  after  the 
attack.     The  point  of  infection,  as  a  rule,  is  the  umbilicus. 

Trismus,  associated  with  paralysis  of  the  facial  nerve  (E .  Rose, 
1870),  is  a  peculiar  form  of  trismus  folloAving  injuries  of  the  head,  and  par- 
ticularly of  the  facial  region.  It  is  sometimes  called  hydrophobic  tetanus, 
from  the  fact  that  attempts  to  swaUow  bring  on  the  spasms.  The  prognosis 
is  more  favorable  than  in  the  other  varieties.  Rose's  trismus  may  pass 
into  a  chronic  or  typhoid  form  of  the  disease,  which  is  followed  by  death. 

Etiology. — The  essential  cause  of  tetanus  is  the  Bacillus  tetani  of 
Nicolaier  (1884),  who  discovered  it  in  garden  earth.  Rosenbach 
demonstrated  its  existence  in  the  wound  secretions  of  tetanic  patients. 
Sternberg  in  1880  produced  tetanus  in  a  rabbit  by  injecting  beneath 
its  skin  mud  from  the  street  gutters  of  New  Orleans.  The  identity  of  these 
bacilh  was  established  in  Koch's  laboratory  (1887).  A  pure  culture 
was  obtained  by  Kitasato  (1889). 

The  ptomains  of  the  bacihus  are  undoubtedly  the  toxic  agents  acting 
through  the  medium  of  the  spinal  cord.  One  of  these,  isolated  from  cultures 
of  the  microorganism,  called  ''tetanin"  (Brieger),  injected  beneath  the 
skin  of  animals,  produced  tetanic  convulsions. 

Wounds  of  the  hands  and  feet  are  said  to  invite  the  occurrence  of  the  dis- 
ease. This  is  probably  due  to  the  greater  exposure  of  these  parts  to  the 
material  containing  the  infective  agent.  Extirpation  of  the  thyroid  gland  has 
been  followed  by  tetanus  (13  cases  reported  by  Weiss).  It  occurs  more 
frequently  after  partial  than  after  total  extirpation  (Billroth),  and  is  said 
to  be  due  to  the  increased  peripheral  irritation  caused  by  the  application  of 
a  large  number  of  ligatures.  The  colored  races  are  attacked  more  frequently 
than  the  Caucasian  race.  The  conditions  of  climate  in  southern  regions  favor 
reproduction  of  the  bacillus.  Conditions  of  soil  also  favor  its  cultivation 
and  propagation. 

Incubation.— The  period  of  incubation  is  extremely  variable  both  in  the 
lower  animals    and   in  man.      This  depends  on   (1)  the  number  of  bacilh 


TETANUS  139 

introduced  (Watson  C  li  e  y  n  c) ;  (2)  the  location  of  the  point  of  infec- 
tion and  the  anatomic  characteristics  of  tlie  surrounding  tissues;  (3)  the  capa- 
city of  the  different  tissues  to  yield  the  ptomains  under  the  influence  of  the 
bacillus.  It  is  also  probable  that  the  degree  of  virulence  of  the  Imcillus  governs, 
to  a  certain  extent,  both  the  duration  of  the  stage  of  incubation  and  the  severity 
of  the  attack. 

Prognosis. — This  will  be  governed  by  the  type  of  the  disease.  The 
attacks  characterized  by  an  early  and  sudden  onset  and  intense  symptoms  are 
more  than  likeh-  to  prove  fatal.  Later  and  slow  development  of  the  symp- 
toms and  a  less  violent  manifestation  of  the  characteristic  spasms  may  end 
in  recovery.  If  the  patient  survives  beyond  the  fourteenth  day,  recovery 
is  the  rule  and  death  the  exception.  Even  a  chronic  state  may  follow  an 
acute  attack;  after  a  period  of  weeks  or  more,  recovery  may  take  place. 
Not  less  than  75  per  cent  of  all  cases  prove  fatal. 

Pathologic  Anatomy.— The  most  constant  pathologic  lesions  found  are 
inflammatory  softening  of  the  gray  substance  of  the  cord  and  dilatation  of 
the  vessels.  Hyperemia  of  the  medulla  oblongata  and  spinal  cord  is  always 
present.  An  entire  absence  of  gross  pathologic  changes  is  characteristic  of 
the  disease. 

Treatment. — The  preventive  treatment  depends  on  an  antiseptic  regi- 
men in  connection  with  all  wounds,  and  the  prompt  removal  of  foreign 
bodies.  Punctured  wounds  of  the  hands  and  feet  are,  as  a  class,  more  liable 
to  be  followed  by  tetanus  than  are  incised  wounds.  As  the  bacillus  of  tetanus 
will  not  grow  in  the  presence  of  oxygen,  it  is  evident  that  a  punctured  wound 
quickly  closed  offers  just  the  conditions  appropriate  for  reproduction  of  the 
germ  if  it  has  been  introduced  into  the  depths  of  the  wound.  Wounds  of  this 
character,  as  well  as  those  inflicted  by  toy  pistols,  the  cartridges  of  which 
contain  earth,  should  be  laid  freely  open  and  thoroughly  disinfected  by  a 
1  :  1000  solution  of  corrosive  sublimate  and  wet  dressings  of  this  applied. 
The  efficiency  of  the  sublimate  solution  is  enhanced  by  the  addition  of 
alcohol  (see  page  60).  Equal  parts  of  95  per  cent  alcohol  and  a  1  :  500  solu- 
tion of  sublimate  may  be  employed.  This  course  is  imperatively  demanded 
in  localities  where  tetanus  is  known  to  follow  trivial  wounds."  Under  no 
circumstances  should  a  small  opening  be  sealed  by  a  dry  dressing. 

Among  the  internal  remedies  employed  in  the  symptomatic  treatment 
of  tetanus.  Calabar  bean,  chloral,  and  opium  are  to  be  mentioned.  Chloroform 
is  largely  used  in  the  South  in  the  hyperacute  cases.  Of  these  remedies. 
Calabar  bean  is  of  value  in  relieving  the  muscular  contractions.  It  is  to  be 
given  in  doses  of  from  one  to  one  and  a  half  grains  of  the  extract  every  three 
or  four  hours.  For  subcutaneous  use  twenty  drops  of  a  1  per  cent  solution 
of  the  extract  is  to  be  administered.  Chloral  acts  by  diminishing  the  reflex 
excitability  of  the_  nerve-centers,  but  it  is  not  a  curative  agent.  It  relieves 
pain,  however,  and  limits  the  spasms  as  well  as  wards  off  the  comailsive 
attacks.  It  should  be  given  to  the  extent  of  from  100  to  200  grains  in  twenty- 
four^  hours  if  necessary.  It  is  sometimes  thought  advantageous  to  combine 
it  with  bromid  of  potassium.  Chloroform  may  be  administered  by  inhalations 
when  required  to  reheve  the  excruciating  pains  and  to  relax  the  contracted 
muscles.  Spasm  of  the  glottis  will  sometimes  prevent  its  use.  Hypodermic 
injections  of  morphin  every  two  or  three  hours  have  been  employed. 


190  ACUTE    WOUND    DISEASES 

Treatment  by  Tetanus  Antitoxin. — Experiments  made  with  the  view 
of  estabhshing  in  animals  immunity  from  the  disease  have  been  carried  on, 
and  it  lias  been  shown  that  the  blood  of  animals  rendered  immune  may  have 
the  effect,  when  injected  into  other  animals,  not  only  of  rendering  these  im- 
mune, but  of  curing  the  disease  when  it  is  established.  The  blood-serum  of 
such  animals,  when  brought  in  contact  with  the  poison  outside  the  body, 
destroys  its  toxic  properties  (Kitasato,  Behring).  The  horse  is 
usually  employed  in  the  production  of  tetanus  antitoxin.  The  dose  of  the 
latter  and  the  frequency  of  the  injection  var}^  with  the  preparation  used, 
the  weight  of  the  individual,  and  the  urgency  of  the  symptoms  as  well  as  the 
improvement  noted.  In  hyperacute  cases  with  a  short  period  of  incubation 
a  large  dose  must  be  employed.  Prophylactic  doses  are  smaller  and  less 
frequently  repeated.  The  average  dose  of  the  antitetanic  serum  furnished 
by  the  Health  I^epartment  of  the  City  of  New  York  is  twenty  centimeters. 
The  injections  are  usually  made  under  the  skin  of  the  back  or  thigh  in  cases 
not  urgent.  In  hyperacute  cases  they  may  be  introduced  directly  into  a  vein. 
Intracranial  injections  of  from  five  to  seven  cubic  centimeters  into  the  frontal 
region  of  each  hemisphere,  after  the  skull  has  been  perforated  on  both  sides, 
have  a  still  greater  efficacy.  The  serum  should  be  allowed  to  diffuse  itself 
slo^\iy  beneath  the  dura.  As  this  method  is  not  devoid  of  danger,  it  should 
be  reserved  for  hyperacute  cases,  and  for  those  in  which  no  benefit  is  derived 
from  the  subcutaneous  and  intravenous  use  of  the  serum.  The  results  follow- 
ing the  use  of  intraspinal  injections  have  been  disappointing  in  my  hands. 

Carbolic  acid,  injected  beneath  the  skin  in  from  ten  to  thirty  drop  doses 
of  a  1  per  cent  solution,  every  three  or  four  hours,  has  been  used  extensively 
in  Italy  (B  a  c  c  e  1 1  i) .  It  is  of  less  value  than  the  serum  treatment. 
There  is  no  objection  to  combining  the  two. 

The  nutrition  of  the  patient  is  to  be  maintained  b}^  nutrient  enemas,  and 
by  means  of  a  tube  passed  into  the  stomach  through  the  nostril,  when  swal- 
lowing is  impossible.  Chloroform  may  be  given  to  effect  this.  The  hydrate 
of  chloral  may  be  given  in  milk  introduced  in  this  way.  It  may  also  be  given 
in  nutrient  enemas.  Physical  and  mental  rest  must  be  enjoined.  The  patient 
should  be  placed  in  a  dark,  quiet  room,  and  every  possible  source  of  excite- 
ment and  noise  avoided. 

HYDROPHOBIA 

This  is  a  disease  of  man  and  certain  other  mammals,  and,  like  tetanus, 
belongs  to  the  class  of  wound  infectious  diseases.  It  arises  from  the  bite  of  a 
rabid  animal,  the  saliva  being  the  infection-bearing  medium.  The  virus  of 
the  disease  may  be  transmitted  to  all  warm-blooded  animals.  The  disease 
in  man  is  caused  most  frecjuently  by  dogs,  both  because  of  opportunity,  and 
because  the  saliva  of  infected  dogs  is  more  virulent  than  that  of  other  animals. 
By  some  it  is  believed,  however,  that  danger  of  the  development  of  hydro- 
phobia is  always  greatest  when  the  bite  is  inflicted  by  a  wolf. 

Clinical  Course. — The  first  onset  of  the  disease  does  not  occur  until 
after  a  comparatively  long  period  of  incubation.  In  rare  instances  this  may 
be  as  short  as  fourteen  days;  it  has  been  prolonged  to  twenty-tA^t)  months. 
The   younger  the   patient,    the  shorter   the    incubative   period,  as   a   rule. 


HYDROPHOBIA  191 

This  sta2;c  of  the  disease  is  said  to  be  lengthened  by  depressing  influences. 
The  heaiiug  of  tlie  wound  is  generally  uninterrupted.  During  the  initial  stage 
of  the  disease  a  reddening  with  burning  and  itching,  and  sometimes  actual  pain 
at  the  site  of  the  scar,  is  observed.  This  may  radiate  along  the  course  of  the 
nerves  of  the  limb.  Anesthesia  and  hyperesthesia  are  also  present  at  times. 
During  this  stage  there  are  some  ill-defined  s>'mptoms,  such  as  melancholia, 
irritability,  and  disturbed  sleep,  alternating  with  restlessness  and  short  periods 
of  joyous  excitement. 

With  the  onset  of  active  symptoms  the  characteristic  symptoms  of  the 
disease  make  their  appearance.  These  refer  to  mental  excitement  conjoined 
with  spasms  of  the  muscles  concerned  in  respiration  and  deglutition.  There 
is  at  first  a  sense  of  choking,  which  is  soon  followed  by  spasms  of  the  lar\'ngeal 
muscles.  A  profuse  salivary  secretion  is  present,  which  becomes  mingled  with 
viscid,  tenacious  mucus  from  the  fauces.  Attempts  to  drink  excite  such  pain- 
ful spasms  of  the  pharyngeal  muscles  that  the  patient  soon  abandons  the  at- 
tempt, and  cannot  be  induced  to  repeat  it.  Spasm  of  the  glottis  also  takes  place 
as  a  result  of  the  effort  to  swallow.  General  tremors  may  occur,  and  even  con- 
vulsions. The  temperature  is  always  increased  to  from  101°  to  103°  F.  The 
pulse  is  not  markedly  increased  at  first,  but  later  on  becomes  rapid  and  feeble, 
and  sometimes  intermittent.  The  skin  is  hot  and  dry;  just  before  the  fatal 
issue  a  cold  and  clammy  perspiration  may  be  present.  Priapism  and  satyria- 
sis are  observed. 

A  most  disturbing  symptom,  present  from  the  first  moment  the  disease  is 
suspected  to  exist,  and  lasting  to  the  very  close,  despite  the  most  positive  assur- 
ances and  consolation,  is  the  fear  of  impending  death.  The  mental  faculties 
are  not,  as  a  rule,  impaired,  though  occasionally  the  patient  has  hallucinations 
of  sound  and  hearing. 

Etiology. — It  can  no  longer  be  doubted  that  hydrophobia  is  a  disease  of 
microbic  origin,  though  its  specific  microorganism  has  not  as  yet  been  dis- 
covered. It  seems  now  very  certain  that  the  \drus  cannot  be  reproduced 
except  Adthin  the  hving  organism.  The  smallest  amount  of  this  introduced 
^Aithin  the  body  will  produce  the  most  serious  consequences.  The  symptoms 
bear  such  a  strong  resemblance  to  those  of  tetanus  that  it  is  probable  that  the 
development  of  the  disease  is  due  to  the  action  of  the  ptomains  of  the  microbes 
on  the  nerve-centers. 

The  specific  virus  seems  to  be  generated  within  the  glandular  appendages 
of  the  mucous  membrane  of  the  mouth  of  the  rabid  animal,  and  is  transmitted 
by  the  saliva.  Only  a  certain  proportion  of  persons  bitten  by  rabid  animals 
contract  the  disease,  about  one-fourth  escaping  (Renault). 

The  route  of  entrance  is  usually  a  punctured  wound  made  by  the  bite  of  a 
rabid  animal,  though  the  saliva  deposited  on  an  abraded  surface  may  suffice 
for  the  inoculation.  The  microbe  does  not  penetrate  the  uninjured  skin  or 
the  mucous  membrane. 

Prognosis. — The  disease  in  man  is  invariably  a  fatal  one.  No  case  of 
recovery  from  genuine  hydrophobia  is  authentically  recorded.  In  the  major- 
ity of  cases  death  occurs  during  the  first  four  days.  It  is  rare  for  the  patient 
to  live  beyond  the  second  day.  The  length  of  time  from  the  infection  of  the 
bite  until  death  takes  place  is  from  the  twentieth  to  the  sixtieth  day. 
Death,  as  a  rule,  occurs  unexpectedly  from  either  apoplexy  or    asphj^ia; 


192  ACUTE    WOUND    DISEASES 

or  rapid  exhaustion  may  carry  off  the  patient.  A  stage  of  paralysis  may  pre- 
cede death,  the  patient  lying  relaxed  from  two  to  eighteen  hours. 

Pathology. — There  are  no  gross  pathologic  changes  in  the  disease.  The 
scar,  in  some  instances,  may  be  red  and  somewhat  swollen ;  this  is  not  by  any 
means  constant,  however.  The  cerebral  ganglia,  particularly  of  the  pneumo- 
gastric  and  trifacial  nerves,  and  the  spinal  and  sympathetic  ganglia  undergo 
certain  distinctive  changes,  inflammatory  tissue  taking  the  place  of  the 
destroyed  nerve  cells.  AA'ell-defined  vascular  lesions  in  the  nerve-centers  of  the 
cord  and  medulla  may  be  detected;  these  are  less  defined  in  the  spinal 
cord,  still  less  in  other  parts  of  the  nervous  system.  An  accumulation  of 
leukoc3'tes  around  the  vessels  in  the  substance  of  the  medulla  and  cord  is  usually 
found.  There  is  well-marked  hyperemia  and  edema  of  the  substance  and  mem- 
branes of  the  brain,  spinal  cord,  and  medulla  oblongata. 

Treatment. — When  a  person  is  bitten  by  an  animal  known  or  suspected 
to  be  rabid,  inasmuch  as  the  virus  is  slowly  diffused  in  the  system,  no  time 
should  be  lost  in  resorting  to  the  most  radical  prophylactic  measures  at  com- 
mand. These  may  be  efficient,  even  if  applied  after  several  clays.  Excision 
of  the  wound  affords  the  best  hope  of  preventing  the  disease.  A  tourniciuet 
should  be  applied  on  the  proximal  side  of  the  wound,  and  in  the  absence  of 
professional  help,  an  attempt  made  to  remove  the  virus  by  suction.  The  tis- 
sues in  the  immediate  vicinity  are  to  be  dissected  out,  and  the  wound  sutured. 

Cauterization  of  the  wound  may  be  most  effectually  performed  with  the 
actual  cautery,  the  point  of  the  Paciuelin  cautery,  if  this  instrument  is  employed, 
being  thrust  deeply  into  the  wound.  The  parts  are  afterward  dressed  antisep- 
tically.     Caustic  potash,  nitric  acid,  and  nitrate  of  silver  are  less  efficient. 

Statistics  show  that  a  large  proportion  of  persons  who  have  been  bitten  by 
hydrophobic  animals  escape  infection  when  these  measures  of  prophylaxis  are 
employed. 

The  inoculation  test  by  which  it  may  be  demonstrated  whether  or  not  the 
animal  is  rabid  is  carried  out  by  killing  the  latter  at  once,  removing  the  medulla, 
and  rubbing  this  up  with  sterilized  salt  solution.  The  emulsion  thus  obtained 
is  injected  into  the  subdural  space  of  a  rabbit.  If  the  virus  of  hydrophobia  is 
present,  the  inoculated  animal  will  speedily  develop  the  disease. 

The  person  bitten  should  be  sent  at  once  to  a  branch  laboratory  of  the  Pas- 
teur Institute,  where  immunization  may  be  promptly  carried  out. 

Pasteur's  Prophylactic  Inoculation. — The  varying  periods  of  incubation 
in  different  cases  suggest  that  this,  the  latent  stage  of  the  disease,  depends 
either  on  the  slow  growth  of  the  microorganisms,  or  on  the  fact  that  they  reach 
the  point  where  they  exert  their  noxious  influence  very  slowly  in  some  cases, 
and  more  rapidly  in  others.  The  differences  in  this  respect  may  depend  on 
the  fact  that  the  tissues  in  which  the  virus  was  originally  implanted  permit 
reproduction  of  the  microbe  but  slowly  in  some  instances,  and  more  rapidly  in 
others.  On  the  other  hand,  it  was  discovered  by  Pasteur  that  if  the  virus  is 
introduced  directly  into  the  brain  of  the  animals,  a  fixed  period  of  incubation 
precedes  the  development  of  the  disease.  Subsequent  inoculations  are  marked 
by  a  still  shorter  period  of  incubation. 

Pasteur  made  the  additional  important  discovery  that  the  virulence  of  the 
infected  spinal  cord  in  rabbits  may  be  diminished  progressively  from  the 
highest  degree  to  the  lowest  or  even  rendered  inert,  according  to  the  length 


HYDROPHOBIA  193 

of  time  tho  cord  is  kopt  in  a  dryiiio-  room,  in  a  pure,  dry  atmosphere.  This  is 
accomplislicd  in  from  sc\-en  to  eight  days.  I'\)iirteen  days'  drving  will  com- 
pletely- destroy  all  A'irulenee.  l^y  using  the  spinal  cords  of  rabbits  treated  in 
this  manner  in  varying  strengths,  commencing  with  the  weakest  and  gradually 
approaching  the  strongest,  he  found  that  when  the  latter  were  reached,  the 
animals  did  not  respond  to  the  inoculation.  In  other  words,  they  became 
immune.  After  demonstrating  the  accuracy  of  these  observations  on  dogs, 
Fasten  r  (July  5,  1885)  applied  the  method  to  persons  bitten  by  rabid  ani- 
mals. The  long  period  of  incubation  enabled  him  to  apply  the  treatment  to 
those  who  came  from  a  distance,  and  during  the  first  five  years  of  its  application 
nearly  eight  thousand  persons  who  had  been  bitten  bv  supposed  rabid  animals 
were  thus  treated.  Of  these,  only  0.92  per  cent  died,  a  most  extraordinary 
savmg  of  human  life,  when  compared  with  the  fact  that  in  former  times  16 
per  cent  died  of  hydrophobia,  all  those  who  were  actually  bitten  by  rabid 
animals,  as  well  as  those  supposedly  bitten,  being  taken  into  account.  As 
those  bitten  by  rabid  wolves  develop  the  disease  much  more  certainly  than 
those  bitten  by  dogs,  a  crucial  test  of  the  method  consisted  in  the  prophylactic 
inoculation  of  this  class  of  cases.  Thirty-eight  were  submitted  to  the  treat- 
ment, and  of  these  only  7.89  per  cent  died.  A  collection  of  one  hundred  un- 
treated cases  of  persons  bitten  by  hydrophobic  wolves  showed  a  mortality  of 
82  per  cent  (Pasteur). 

In  view  of  the  results  obtained,  the  deadly  character  of  the  disease,  and  its 
probable  development  in  those  bitten  by  a  hydrophobic  animal,  it  is'  recom- 
mended that  all  persons  who  have  been  bitten  by  animals  suspected  to  be  rabid 
be  subjected  to  Pasteur's   prophylactic  inoculation. 


14 


SECTION  V 
THE  CHRONIC  SURGICAL  INFECTIONS 

SYPHILIS 

This  disease  has  been  kno^^-n  since  the  very  earliest  times,  if  ^ve  may  judge 
from  the  fact  that  its  symptoms  are  described  in  the  ancient  literatures  of  the 
earliest  known  races,  such  as  those  of  China,  Mexico,  Peru,  Greece,  and  Rome, 
and  in  sacred  writings  of  the  Hebrews.  Renewed  interest  in  the  disease  was 
awakened  in  the  fifteenth  century,  coincidentally  with  the  discovery  of  the  con- 
tinent of  North  America,  and  on  this  account  it  has  been  supposed  by  some 
writers  that  the  disease  was  introduced  from  this  continent.  It  is  probably  true 
that  the  impulse  given  to  traffic  between  nations  by  that  discovery  led  to  exten- 
sion of  the  disease.  Communities  theretofore  immune  became  infected,  and, 
as  is  usual  where  the  soil  on  which  specific  infections  are  implanted  is  virgin, 
the  epidemics  of  the  disease  were  marked  by  exceptional  se^'erity.  At  the 
present  day  it  exists  practically  all  over  the  world,  particularly  among  those 
nations  with  great  commercial  activities,  and  in  the  crowded  centers  of  trade. 
Rural  populations  are  happily  quite  free  from  it. 

Syphilis  is  a  specific  infectious  and  chronic  disease,  limited  to  man,  having  its 
origin  either  from  the  contact  of  a  sound  indi^ddual  with  one  infected  ^vith  the 
disease  (acquired  syphilis)  or  from  heredity.  The  disease,  beyond  question, 
is  to  be  classed  with  the  infectious  granulomas,  and  is  caused  by  the  introduc- 
tion of  a  specific  microorganism  into  the  human  economy.  The  infectious 
agent  is  transmitted  through  the  medium  of  fluids  furnished  by  the  pathologic 
tissues  of  infected  individuals.  A  number  of  observers  have  claimed  to  have 
discovered  a  specific  microorganism  of  syphilis.  The  latest  of  these,  M  a  x 
Joseph  and  P  i  o  r  k  o  w  s  k  i  ,  isolated  a  bacillus  which,  when  cultivated 
on  sterilized  placentae,  closely  resembled  that  of  diphtheria.  When  it  was 
transferred  to  artificial  media  and  cultivated  for  successive  generations,  the  size 
and  form  as  well  as  the  numbers  and  vigor  of  the  bacilli  diminished  consider- 
abl}',  these  being  restored  by  reinoculation  on  blood-serum. 

The  disease  is  conveyed  by  inoculation  through  the  skin  or  mucous  mem- 
brane, or  the  \arus  may  exist  in  the  embryo  or  be  transferred  through  the  pla- 
centa. The  inoculation  takes  place  most  frequently  from  immediate,  rarely 
through  mediate,  contact.  In  the  vast  majority  of  cases  the  disease  is  con- 
tracted during  coitus  and  is  therefore  classed  as  a  venereal  disease.  It  may  be 
contracted,  however,  by  kissing  a  person  infected  with  the  disease,  in  examina- 
tions of  syphilitics  or  in  operations  on  them,  or,  rarely,  by  contamination  from 
any  article  on  which  syphilitic  virus  has  been  spread.  The  last  named  is 
what  is  known  as  "mediate  infection." 

The  Course  of  Acquired  Syphilis. — In  the  acquired  form  of  the  dis- 
ease the  virus  enters  the  organism  at  the  point  of  infection  and  always  begins 
as  a  hard  chancre.     This  appears  after  a  relatively  definite  and  characteristic 

194 


SYPHILIS  195 

intor\'al  following  the  exposure  to  the  virus  and  the  reception  of  it.  A 
so-called  "primary  incubation  period,"  extending  usually  from  two  to  four 
weeks,  inter\-ones  betwinni  the  reception  of  the  virus  and  the  appearance  of  the 
chancre,  or  initial  lesion,  as  it  is  sometimes  called.  This  is  followed  by  the 
"secondary  incubation"  period,  occupying  from  two  to  eight  weeks,  after 
which  there  develops  the  primary  regionary  lymphadenitis,  then  the  secondary 
general  lymphadenitis.  Coincidentally  w-ith  the  latter,  in  many  cases,  symp- 
toms which  usher  in  the  acute  infectious  diseases  are  observed,  such  as  nervous 
disturbances,  debility,  anemia,  elevation  of  temperature,  headache,  and  pains 
in  the  extremities;  less  frequently  i^eriostitis  and  prodromic  papules. 

At  the  end  of  the  second  incubation  period  further  evidences  of  constitu- 
tional syphilis  appear.  There  is  frecjuently  more  or  less  febrile  movement  pre- 
ceding the  outbreak  of  the  first  exanthem,  namel}^,  the  roseola.  The  heating 
of  the  surface  may  precipitate  the  occurrence  of  the  rash,  as,  for  instance,  when 
a  warm  bath  or  excessive  exertion  immediately  precedes  the  latter.  The 
roseola  makes  its  appearance  in  the  majority  of  instances  in  from  seven  to  nine 
weeks  after  the  original  infection.  From  this  time  on,  the  course  of  the 
disease  is  that  of  an  irregularly  relapsing  chronic  infectious  disease.  The  re- 
lapses alternate  with  periods  of  more  or  less  complete  latency,  as  far  as  rasiy 
be  judged  by  the  symptoms.  It  is  not  to  be  supposed,  however,  that  the  dis- 
ease itself  is  not  progressive,  even  during  these  periods  of  apparent  quiescence. 
A  gradual  and  continuous  progression  of  the  disease  takes  place  from  the 
moment  the  infection  gains  entrance,  and  no  distinct  line  of  demarcation  can  be 
made  between  the  successive  manifestations  of  the  disease  as  they  appear  in 
any  individual  case.  A  general  involvement  of  the  lymphatic  glandular  sys- 
tem, the  so-called  "secondary  lymphatic  adenopathy,"  as  distinguished  from 
the  primary  lymphatic  adenopathy,  which  occurs  near  the  site  of  the  chancre, 
marks  the  entrance  of  the  toxic  products  of  the  latter  into  the  general  circula- 
tion, and,  from  this  time  on,  the  characteristic  phenomena  of  the  infection  are 
observed  as  the  evolution  of  the  disease  progresses.  The  red  blood-cells  com- 
monly decrease  and  the  leukocytes  increase.  The  general  lymphatic  involve- 
ment manifests  itself  by  a  somew^hat  symmetric  enlargement  of  the  glands, 
thereby  differing  from  the  adenopath}^  near  the  site  of  the  chancre,  which  is 
rather  asymmetric.  These  phenomena,  together  with  those  already  men- 
tioned, stamp  this  as  a  steadily  progressive  infection;  the  halt  between  the 
appearance  of  the  initial  sore  or  chancre  and  the  occurrence  of  the  skin  erup- 
tions is  more  apparent  than  real. 

All  the  organs  are  more  or  less  disturbed  in  their  function.  The  spleen, 
liver,  and  stomach  notably  take  part  in  these  disturbances.  The  nervous  sys- 
tem may  suffer,  as  showm  by  the  neuralgic  pains  along  nerve-trunks  and  by  the 
peripheral  pains  as  well.  Febrile  disturbances  are  not  uncommon  (syphilitic 
fever) .  There  are  pains  in  the  bones  and  joints ;  synovial  effusions  may  occur. 
In  severe  infections  the  lassitude  and  depression  are  profound,  with  mental 
lethargy,  followed  by  attacks  of  syncope  and  headache. 

All  grades  of  severity  of  the  disease  may  be  observed,  and  the  terms 
"benign"  and  "malignant"  have  been  employed  to  designate  these.  These 
terms  have  but  a  relative  significance,  particularly  the  term  known  as  benign, 
though  all  grades  of  malignancy  also  may  be  recognized. 

Benign  Syphilis. — This  includes  (1)  cases  with  mild  and  transitory  symp- 


196  THE    CHRONIC   SURGICAL   INFECTIONS 

toms;  (2)  cases  with  relapsing  or  persistent  superficial  symptoms.  Those 
cases  with  mild  and  transitory  symptoms  may  present  an  apparent  arrest  of 
the  disease  after  the  appearance  of  a  hard  chancre  and  the  presence  of  the 
characteristic  local  lymphatic  glandular  changes,  the  individual  thereafter 
failing  to  react  to  the  disease.  As  far  as  any  outward  sign  of  generalization  of 
the  latter  may  indicate,  the  patient  is  immune,  and  cannot  thereafter  be  inocu- 
lated. Or,  as  more  frequently  happens,  lymphatic  glandular  enlargement 
occurs  in  the  occipital  region  or  along  the  nucha,  and  later  on  along  the  sterno- 
mastoid  muscle.  The  disease  then  progresses  to  the  production  of  a  macular 
skin  eruption  on  the  abdomen  or  over  the  chest,  or  both.  With  the  subsi- 
dence of  this  exanthem  the  disease  appears  to  terminate.  A  case  may  pursue 
the  course  above  outlined  with  absolutely  no  treatment.  The  symptoms 
present,  though  typic,  are  of  an  astonishingly  mild  type.  These  cases  differ 
from  the  foregoing  in  the  degree  of  immunity  exhibited. 

In  the  second  group  of  cases,  namely,  those  with  relapsing  or  persistent 
superficial  symptoms,  the  manifestations,  both  of  the  initial  lesion  and  of  the 
general  disease,  are  in  every  respect  typic,  yet  at  no  time  scarcely  more  than 
an  annoyance.  The  special  features  of  this  type  are  the  persistency  of  the  re- 
lapses and  the  mildness  of  the  symptoms,  the  latter  of  which  relate  particularly 
to  the  superficial  skin  eruptions.  The  majority  of  cases  of  syphiUs  belong  to 
this  group.  There  can  be  no  doubt  that,  in  the  course  of  the  natural  history  of 
the  disease,  in  a  large  number  of  cases  the  destructive  lesions  neA^er  develop. 
This  will  account  for  the  so-called  "cures"  by  infinitesimal  dosage,  mind  cures, 
as  well  as  for  the  ignored  cases.  Nevertheless,  the  fact  should  not  be  overlooked 
that  the  mildest  cases  in  the  beginning  may  become  the  severest  in  the  end. 
Therefore  there  should  be  no  relaxation  in  vigilance  in  respect  to  even  the 
mildest  cases. 

Malignant  Syphilis. — This  is  fortunately  a  rare  form  of  infection.  The 
malignancy  is  probably  due  either  to  an  extraordinary  susceptibility  of  the 
individual  to  the  disease,  as  occurs  when  the  latter  is  introduced  among  a  race 
or  people  for  the  first  time,  or  to  a  lack  of  resistance  to  the  infection  and  its 
rapid  propagation  in  the  tissues  of  the  patient  whereby  the  entire  organism  is 
overwhelmed  by  the  virulence  of  the  poison. 

The  malignancy  of  this  class  of  cases  may  be  exhibited  early  in  the  case  or 
soon  after  the  chancre  stage,  and  continue  only  through  the  exanthem  period, 
this  including  the  time  when  lesions  of  the  mucous  membrane  and  general  en- 
largement of  the  glands  occur  (the  secondary  stage  of  R  i  c  o  r  d) .  Or,  it  may 
continue  and  manifest  itself  in  connective-tissue  hyperplasia,  or  gummatous 
deposits  (^syphilomas),  which  constitute  the  late  stage  of  the  disease 
(the  tertiary  stage  of  R  i  c  o  r  d) .  In  the  mean^vhile  the  patient  shows  signs 
of  a  deterioration  of  the  general  system  (syphilitic  cachexia),  with  high  fever, 
loss  of  flesh,  and  pains  in  various  parts  of  the  body — in  fact,  all  the  evidences  of 
a  profound  systemic  poisoning.  Disturbances  of  the  nervous  system,  such  as 
aphasia,  epilepsy,  coma,  and  paralysis,  have  been  observed.  Degeneration 
takes  the  place  of  resolution  in  the  case  of  the  lesions.  Ulcers,  eruptive  and 
gummatous,  n;pia,  and  even  gangrenous  areas  may  occur  at  the  site  of  the  rather 
sparse  lesions.  Gummatous  deposits  undergo  processes  of  disintegration,  lead- 
ing to  deep  and  gangrenous  excavations  where  these  can  communicate  ^Yith  the 
surface.     When  restoration  of  these  deposits  takes  place  the  implicated  organs 


SYPHILIS  197 

are  greatly  damaged.  Exceptionally  all  these  destructive  manifestations  ma}^ 
occur  early  in  the  disease  (malignant  precocious  syphilis) . 

Finally,  the  fact  cannot  be  too  forcibly  impressed  that  the  different  types 
of  the  disease,  as  expressed  by  the  terms  "benign"  and  "malignant,"  may  be 
merged  the  one  into  the  other.  Chief  among  the  causes  for  this  interchange  may 
be  mentioned  the  influences  of  environment,  constitutional  conditions,  and  the 
effects  of  treatment. 

It  has  been  customary  to  divide  acquired  syphilis  into  stages,  namely,  the 
primary,  the  secondary  and  the  tertiary  (R  i  c  o  r  d) .  This  division,  though 
artificial  to  a  considerable  extent,  is  convenient  for  purposes  of  clinical  study 
and  therapeutic  considerations. 

The  primary  stage  covers  the  two  incubation  periods  before  mentioned, 
namely,  that  which  intervenes  between  the  reception  of  the  virus  and  the 
appearance  of  the  chancre  (the  primary  incubation  period),  and  the  interval 
between  the  appearance  of  the  chancre  and  the  occurrence  of  the  characteristic 
exanthem,  the  roseola  (the  secondary  incubation  period).  The  secondary 
stage  of  the  disease  commences  after  an  average  interval  of  four  or  five  weeks 
and  is  ushered  in  b}'  the  exanthematous  outbreak  of  roseola  (the  macular  syph- 
ilide).  The  tertiary  period  commences  after  the  lapse  of  two  years  on  an 
avei'age,  and  embraces  what  are  known  as  the  late  manifestations  of  the  disease, 
the  gummas.  The  gummatous  lesions  may  be  absent,  even  in  the  cases  un- 
treated; their  presence  is  not  to  be  expected  in  those  who  have  been  subjected 
to  continuous  mercurial  treatment  for  two  years. 

The  Lesions  of  the  Primary  Stage. — After  the  primary  period  of 
incubation,  this  lasting  from  twelve  to  thirty  clays  (exceptionally  even 
sixty  days),  the  seat  of  inoculation  undergoes  certain  characteristic  changes 
which  culminate  in  what  is  known  as  the  initial  lesion,  primary  sore,  or 
.chancre.  The  chancre  is  usually  single  and  painless  and  may  be  o^^erlooked 
owing  to  its  situation  (within  the  urethra  in  the  male,  and  between  the  labial 
folds  in  the  female,  or  in  the  mouth  or  throat).  The  primary  adenopathy  con- 
sists of  an  indolent  enlargement  of  the  lymphatic  glands  in  anatomic  relation 
with  the  primary  sore  (bubo) . 

The  Lesions  of  the  Secondary  Stage. — These  follow  the  secondary 
period  of  incubation  in  the  primary  stage  (see  page  195) .  Sore  throat,  syphilitic 
roseola  (macular  syphilide) ,  and  painless  enlargement  of  the  lymph-glands  are 
the  earliest  manifestations  usually  observed  in  the  secondary  stage.  The  ante- 
rior and  posterior  chains  of  glands  in  the  cervical  region,  the  epitrochlear 
glands  and  those  in  the  axillae  and  groins  are,  as  a  rule,  easily  palpated.  Later 
on,  and  usually  coincidentally  with  the  disappearance  of  the  roseola,  another 
type  of  skin  eruption  makes  its  appearance,  namely,  the  papular  syphilide. 
Exceptionally,  however,  the  latter  appears  before  the  subsidence  of  the  roseola. 
The  papular  syphilide  is  a  small,  rounded,  and  distinctly  indurated  nodule  of  a 
brownish-red  color.  It  usually  appears  first  in  the  localities  first  affected  by  the 
roseola,  namely,  on  the  abdomen,  chest,  and  back,  and  at  a  later  period  on  the 
arms  and  thighs ;  finally,  on  the  palms  of  the  hands  and  the  soles  of  the  feet.  Or 
this  order  may  be  reversed.  Coincidentally  with  the  cutaneous  eruption  small 
superficial  erosions  appear  on  the  mucous  membrane  of  the  mouth  and  pharynx 
(mucous  patches).  The  favorite  locations  for  these  lesions  of  the  mucous 
membrane  are  the  sides  of  the  tongue,  the  hning  of  the  cheeks,  the  tonsils  and 


198  THE    CHRONIC    SURGICAL   INFECTIONS 

pharynx,  and  the  hps  and  angle  of  the  mouth.  Mastication  is  painful  and  the 
flow  of  saliva  anno>-ing.  About  the  time  when  the  above  symptoms  decline, 
or  about  the  third  month,  the  symptom  of  the  falling  out  of  the  hair  appears. 
This  may  amount  to  only  a  general  thinning  of  the  hair,  or  complete  absence  of 
hair  in  patches  may  result  (syphilitic  alopecia).  The  hair  in  different  locali- 
ties of  the  body  may  be  affected,  with  the  exception  of  the  eyelashes;  the  latter 
are  invoh'ed  only  through  ulcerative  action.  The  hair-follicles  may  be  involved 
in  an  erythematous,  papular,  or  pustular  eruption,  and  scales  or  scabs  appear  on 
the  scalp  in  conjunction  -with  the  alopecia.  This  symptom  of  the  falling  out  of 
the  hair  may  last  for  a  variable  time.  It  disappears  spontaneously  in  a  short 
time,  as  do  most  of  the  symptoms  of  this  period  of  the  disease,  even  in  cases 
that  are  not  treated.  Permanent  baldness  ma}^  result  when  the  papillae  are 
destroyed  and  the  hair-follicles  obliterated  by  the  presence  of  ulcerative  lesions ; 
this  may  also  follow,  to  a  greater  or  lesser  extent,  a  simple  erythematous  or  pap- 
ular eruption.  After  the  disappearance  of  the  first  exanthems,  the  latter 
may  reappear  in  different  shapes  and  combinations  (recurrent  syphilides).  A 
papular  and  a  pustular  eruption  may  appear  either  separately  or  in  combina- 
tion, or  these  may  occur  with  either  a  scaly  or  a  pustulo-crustaceous  erup- 
tion, or  both.  Other  lesions  occurring  in  this  period,  and  somewhat  allied  to 
mucous  patches,  are  the  so-called  condylomas  or  moist  tubercles.  These  are 
situated  in  moist  localities  and  on  certain  mucous  membranes  {e.  g.,  in  the 
larynx),  about  the  anal  aperture  and  on  the  genitals.  In  the  latter  situa- 
tions they  appear  as  broad,  flat  warts  with  a  purulent  discharge  (condylomata 
lata)  and  with  a  tendency  to  vegetate,  though  vegetating  condylomas  or  papil- 
lomas are  not  necessarily  of  syphilitic  origin.  Finally,  within  the  first  or  early 
in  the  second  year  there  may  appear  small  circumscribed  and  painless  swellings 
under  the  skin,  perceptible  only  to  the  touch  (precocious  gummas).  These 
are  of  rapid  growth,  become  adherent  to  the  skin,  and  appear  as  inflamed  indu- 
rations; the  red  color  soon  changes  to  a  dull  or  coppery  hue.  Softening  takes 
place;  ulceration,  however,  is  not  the  rule  in  cases  subjected  to  treatment.  As 
resolution  takes  place  the  gumma  slowly  disappears,  leaving  a  peculiar  copper- 
colored  patch  on  the  skin.  If  ulceration  occurs,  the  softening  begins  early, 
fluctuation  is  felt,  and  the  skin  at  the  site  of  the  gumma  breaks  down  in  several 
places.  The  points  where  softening  first  occurs  coalesce  rapidly,  and  an 
ulcer  with  a  greenish  base  and  with  undermined,  sometimes  everted  edges, 
results.  Exceptionally,  the  development  of  precocious  gummas  may  be  slow 
and  insidious.  In  other  cases  these  lesions  are  accompanied  b}^  severe  neu- 
ralgic pains  and  excpisite  tenderness  of  the  tumors. 

The  Lesions  of  the  Tertiary  Stage. — This  stage  of  the  disease  may 
never  be  reached,  even  in  untreated  cases;  in  those  that  have  been  subjected 
to  proper  mercurial  treatment  for  two  years  the  so-called  tertiary  symptoms 
are  practically  wanting.  The  evolution  of  the  disease  at  this  stage  is  usually 
slow  and  insidious,  and  always  erratic  in  its  manifestations.  The  latter  consist 
essentially  of  connective-tissue  hyperplasia,  or  of  masses  made  up  of  collections 
of  small  spheroidal  and  epithelial  cells,  and  occasional  giant  cells  (gummas). 
T'hese  lesions  are  situated  in  the  skin,  deep  in  the  subcutaneous  connective  tis- 
sue, in  the  mucous  membranes  and  in  other  structures.  The  larger  gummas 
consist  of  firm  nodules  with  a  cheesy  or  necrotic  center  and  present  a  somewhat 
characteristic  grayish-white  appearance;  they  are  inclosed  in  a  rather  ill- 
defined  translucent  capsule. 


SYPHILIS  199 

No  organ  or  tissue  of  the  body  is  exempt  from  the  infiltrations  or  deposits 
of  these  late  manifestations  of  the  disease,  and  the  symptoms  to  which  these 
latter  give  rise  are  as  \-aried  as  are  the  functions  of  the  parts  attacked.  In 
the  skin  patches  serpiginous  ulcers,  rupia,  and  pustulo-crustaceous  syphilides 
are  observed.  Ciummatous  deposits,  followed  by  ulcerations,  occur  in  the 
subcutaneous  connective  tissue.  These  lesions,  as  a  rule,  leave  pronounced, 
and  sometimes  characteristic,  scars.  Those  occurring  on  mucous  mem- 
brane, particularly  that  of  the  pharynx,  increase  rapidly  and  break  down 
early,  causing  great  loss  of  tissue.  Necrosis  of  the  hard  palate  and  of  the  bones 
of  the  nose  occurs,  with  interference  ^^ith  articulate  speech  in  the  case  of 
the  former,  and  facial  deformity  in  the  case  of  the  latter.  Syphilitic  deposits 
may  take  place  in  the  lungs,  liver,  kidneys,  and  heart — in  fact,  in  all  the 
internal  organs.  The  central  nervous  system  is  attacked  with  relative  fre- 
quency. The  bones  and  joints,  as  well  as  the  tendons,  muscles,  and  bursae,do 
not  escape.  A  cachexia  which  is  out  of  all  proportion  in  its  intensity  to  the 
organic  changes  present  develops  (syphilitic  cachexia). 

In  favorable  cases,  or  those  in  which  the  late  symptoms  just  described 
yield  to  treatment,  there  occurs  a  tendency  to  a  natural  decline  of  the  disease. 
This,  however,  may  not  occur  until  irreparable  damage  to  one  or  more  of 
the  vital  organs  has  been  done,  and  permanent  impairment  of  the  health  has 
taken  place.  Death  as  a  direct  result  of  the  syphilitic  infection,  however, 
is  not  common, 

THE  GENERAL  TREATMENT  OF  SYPHILIS 

The  self-limiting  nature  of  the  disease  is  now  fully  established.  Women 
are  particularly  fortunate  in  this  respect;  in  men  also  the  disease  occasionally 
runs  its  course  to  recovery  of  health  without  any  treatment  whatever.  This 
circumstance  has  led  to  much  heated  discussion  as  to  the  proper  methods 
to  be  employed  to  protect  the  patient  against  the  ravages  of  the  disease. 
The  principal  contention  in  this  regard  is  in  respect  to  the  administration 
of  mercury.  Without  entering  into  the  merits  of  this  discussion,  it  may  be 
said  that  the  experience  of  the  profession  for  centuries  has  been  in  favor  of 
this  drug.  Since  the  disease  is  one  whose  symptoms  disappear  spontane- 
ously in  a  large  number  of  cases,  it  is  no  wonder  that  many  vaunted 
cures  have  been  urged.  The  use  of  mercury  in  one  way  or  another,  however, 
has  been  for  centuries  the  chief  reliance  in  the  treatment  of  this  affection, 
and  is  likely  to  remain  so.  With  the  sole  exception  of  quinin  in  the  treat- 
ment of  malarial  diseases,  the  influence  of  mercuiy  on  syphilis  stands 
uniciue  in  the  history  of  therapeutics.  As  the  benefits  to  be  derived  from 
its  use  are  fully  realized,  the  only  question  today  relates  to  methods  of 
administration  whereby  the  maximum  amount  of  benefit  may  be  derived 
A\'ith  the  minimum  of  harm. 

The  objects  of  the  rational  specific  treatment  of  syphilis  are  (1)  to  sup- 
press harmful  symptoms  already  in  existence;  (2)  to  prevent  the  occurrence 
of  the  connective-tissue  infiltrations  and  gummatous  deposits  of  the  later 
stage  of  the  disease;  (3)  to  prevent  the  spread  of  the  disease  by  (a)  inoculation 
and  (/))  transmission  to  offspring;  (4)  to  prevent  damage- to  important  struc- 
tures and  organs,  and  unsightly  scars.  The  means  to  be  employed  for  the 
attainment  of  these  objects  is  the  judicious  use  of  the  preparations  of  mercury 


200  THE    CHRONIC   SURGICAL    INFECTIONS 

and  iodin.  The  term  "specific"  as  applied  to  these  remedies  relates  to 
their  peculiar  value  in  the  control  of  the  symptoms.  But  no  one  can  say, 
in  a  given  case,  that  the  disease  is  cured,  even  after  a  prolonged  exhibition  of 
these  remedies,  for  it  will  occasionally  show  fresh  manifestations  of  its  con- 
tinued existence  after  prolonged  treatment  and  absence  of  all  symptoms  for 
years. 

The  proper  time  to  begin  the  systematic  medication  in  syphilis  is  on 
the  appearance  of  the  general  manifestations.  The  reasons  for  this  are  (1) 
that  the  diagnosis  may  be  assured  beyond  a  doubt;  (2)  that  the  pa- 
tient himself,  on  whom  depends  almost  entirely  the  success  of  the  treatment, 
may  have  convincing  proof  of  his  condition  and  persist  in  the  treatment. 
Exceptionally,  the  treatment  may  be  begwn  earlier,  but  this  is  always  at  the 
risk  of  unnecessary  treatment,  or  the  loss  of  confidence,  and  hence  interest, 
on  the  part  of  the  patient. 

The  Hygienic  Treatment  of  Syphilis. — The  importance  of  hygienic 
surroundings  for  the  patient  cannot  be  overestimated.  Every  effort  should 
be  made  to  maintain  the  general  health  at  its  very  best,  in  order  to  diminish 
as  much  as  possible  the  unfavorable  character  of  the  symptoms.  It  is 
unquestionably  true  that  broken-do^\^l  individuals  in  the  declining  years  of  life 
may  acquire  syphilis  which  will  give  rise  to  only  mild  symptoms,  and  that 
in  spite  of  neglect  and  dissipation,  while,  on  the  other  hand,  young  men  in 
the  best  of  health  up  to  the  time  of  infection  suffer  from  a  virulent  form  of 
the  disease  notwithstanding  every  care;  yet  these  facts  do  not  militate 
against  the  necessity  for  husbanding  in  every  particular  the  vital  resources  of 
the  patient. 

The  precautions  to  be  taken  relate  particularly  to  the  ordinary  rules  of 
everyday  life.  Cleanliness  of  the  body  by  daily  bathing  is  important.  No 
special  dietary  need  be  laid  down  for  the  syphilitic  beyond  what  is  required 
in  usual  health  except  that,  during  the  existence  of  mouth  or  throat  lesions, 
articles  of  food  that  may  tend  to  irritate  these  should  be  avoided.  Wine  or  beer 
in  moderation  may  be  allowed  if  taken  only  at  meals;  unless,  however,  the 
denial  of  these  is  a  very  great  deprivation  to  the  patient,  it  is  safest,  in  order 
to  avoid  the  possibility  of  alcoholic  excesses,  to  enforce  total  abstinence. 
Acids  may  be  allowed  unless,  under  some  special  exigency,  mercury  is  being 
pushed  and  salivation  feared.  When  irritable  conditions  of  the  stomach  and 
liowels  supervene  as  the  result  of  necessary  medication,  these  may  sometimes 
be  avoided  by  a  change  in  diet.  This  failing,  corrective  medication,  such  as 
the  preparations  of  bismuth,  bicarbonate  of  soda,  and  finally  small  doses  of 
opium,  may  be  tried  before  the  antisyphilitic  remedies  are  suspended.  Cachec- 
tic states  demand  ferruginous  and  other  tonics,  change  of  air  if  these  fail,  and 
finally  of  occupation  as  well.  Among  the  health  resorts  the  Hot  Springs  of 
Arkansas  have  acquired  a  well-deserved  reputation.  A  sojourn  at  any  one 
health  resort  is  not  calculated  to  be  of  benefit. 

Due  attention  must  be  paid  to  the  hygiene  of  the  mouth.  The  teeth 
should  be  regularly  cared  for  by  a  dentist,  all  ragged  or  projecting  rough 
surfaces  corrected  and  tartar  prevented  from  accumulating.  Mucous  patches 
and  resulting  ulcerative  conditions  demand  that  the  greatest  care  be  taken 
to  avoid  irritating  articles  of  food  and  drink,  since,  under  the  most  favorable 
conditions,  these  lesions  are  frequently  difficult  of  management.      Smoking 


SYPHILIS  201 

should   be   prohibited   during   the    active   existence   of   mouth   lesions,  and 
a  syphilitic  should  not  be  permitted  to  chew  tobacco  under  any  circumstances. 

The  tendency  to  the  occurrence  of  superficial  lesions  (excoriations,  con- 
dylomas, and  ulcerations),  in  localities  where  the  skin  is  thin  and  less  resistant, 
and  at  the  mucocutaneous  junctions,  demands  that  special  precautions  be 
taken  as  to  cleanliness  of  the  genitals  and  of  the  anal  region.  Washing  the 
latter  with  soap  and  water  after  each  defecation  is  not  unwise  nor  uncalled 
for.  The  accumulation  of  moisture  in  these  parts  should  be  corrected  by 
the  use  of  some  antiseptic   drying   powder,  in  addition  to  frequent   bathing. 

The  Specific  Treatment  of  Syphilis. — This  should  never  be  com- 
menced until  indubitable  evidences  of  the  existence  of  the  disease  are  mani- 
fest (vide  supra).  The  specific  medicaments  emplo}'ed  in  the  treatment  of 
the  disease  are  practically  limited  to  the  preparations  of  mercury  and  iodin. 
The  influence  of  the  former  is  more  especially  exercised  in  the  early  stages 
of  the  disease,  while  the  latter  is  particularly  useful  in  the  later  manifesta- 
tions, or  those  dependent  on  gummatous  deposits.  More  or  less  influence 
is  exercised,  however,  by  both  drugs  in  all  stages  of  the  disease,  and  one  may 
be  employed  to  supplement  the  action  of  the  other  (the  mixed  treatment). 

There  can  be  no  question  that  the  tonic  effects  of  mercury  administered 
to  syphilitics  rest  on  entirely  competent  clinical  proof  (K  e  y  e  s) .  The 
drug  should  be  given  in  sugar-coated  granules  of  the  protiodid  (Gamier 
and  Lamoureux's)  in  increasing  per  cliem  allowances  until  the  point  of 
toleration  (tenderness  of  the  gums,  colicky  pains,  etc.)  is  reached,  care 
being  taken  that  the  patient's  diet  is  such  as  not  to  provoke  any  of  the 
sj'mptoms  which  it  is  expected  that  the  mercury  will  produce,  e.  g.,  indiges- 
tion, diarrhea,  etc.  The  full  limit  being  reached,  the  "tonic  dose"  consists 
of  one-half  the  per  diem  dosage  required  to  produce  the  undoubted  and  un- 
desirable effects  of  the  drug.  Individual  cases  may  be  able  to  tolerate  only 
a  still  smaller  dose.  Mercun,'  may  be  employed  either  by  internal  adminis- 
tration, by  external  treatment,  or  by  subcutaneous  method.  The  protiodid 
is  the  preferable  preparation  for  internal  use.  A  preparation  that  is  uniform 
in  its  effects,  is  properly  protected  against  change  by  climate,  and  3'et  one  that 
is  promptty  released  from  its  protective  environment  to  be  acted  on  in 
the  stomach,  such  as  sugar-coated  granules  of  a  trustworthy  manufacture, 
should  be  selected.  These  should  be  given  after  meals  twice  daily;  they 
should  be  commenced  \\i\\\  one  granule  at  a  dose  and  continued  in  an 
increasing  dosage  every  fourth  day  by  adding  a  granule  at  successive  times 
of  administration.  That  is  to  sa}",  on  the  morning  of  the  fourth  day  an 
extra  granule  is  added ;  on  the  fourth  succeeding  day  an  extra  granule  is 
added  to  the  midday  dose,  and  again  on  the  fourth  succeeding  day  an  extra 
granule  is  added,  this  time  to  the  evening  dose.  This  is  continued  until  the 
point  of  toleration  is  reached  {vide  supra).  The  latter  varies  in  different  indi- 
viduals. 

When  the  limit  of  dosage  of  the  individual  is  reached,  the  question  of 
continuing  this,  or  of  dividing  it  by  two  (the  tonic  dose),  must  be  decided  by 
the  patient's  condition.  If  the  case  is  urgent  the  use  of  the  protiodid  may 
be  continued,  its  use  being  combined  with  some  preparation  of  iron  to  combat 
the  tendency  to  anemia  due  to  both  the  presence  of  the  disease  and  the  effects 
of  such  large  doses  of  the  drug,  until  either  the  urgent  symptoms  subside  or 


202  THE    CHRONIC   SURGICAL    INFECTIONS 

the  more  pronoimced  effects  of  the  drug  are  obtained.  A  tonic  dose  should 
then  be  substituted  for  the  full  dose,  and,  unless  a  return  to  the  latter  is 
demanded  by  an  outbreak  of  symptoms  of  an  unusual  character,  it  should  be 
continued  uninterruptedly  for  at  least  two  years.  During  this  time  it  may 
be  necessary  to  alternate  the  tonic  with  the  full  dose  many  times.  In  case 
of  the  occurrence  of  an  intercurrent  malady  the  administration  of  the  mercur}' 
may  be  temporarily  suspended.  After  six  months,  if  everything  goes  well, 
one-third  of  the  original  full  dose,  instead  of  one-half,  may  be  considered  as 
the  tonic  dose. 

When  the  dose  has  been  satisfactorily  adjusted  to  the  requirements  of  the 
case,  and  two  A^ears  have  passed,  the  treatment  should  be  alternated  with 
periods  of  rest  of  a  month's  duration.  The  drug  should  thus  be  given  every 
other  month  for  six  months.  At  the  end  of  this  time  treatment  should  be 
suspended  pending  further  manifestations.  If,  at  the  end  of  another  six 
months,  the  patient  shows  no  further  signs  of  the  disease,  he  is  to  be  con- 
sidered cured  and  may  be  allowed  to  marry. 

In  the  administration  of  mercury  by  the  inunction  method  mercurial 
ointment  is  employed.  From  30  to  60  grains  is  the  daily  dose  for  an  adult. 
Mercurial  vasogen  is  also  employed.  The  ointment  should  be  applied  to  por- 
tions of  the  body  free  from  hair  and  should  be  well  rubbed  in  once  daily,  at 
night  if  possible.  A  new  location  for  the  inunction  should  be  selected  each 
day  until  all  of  the  available  parts  of  the  body  have  been  employed  for  the 
purpose.  The  patient  may  make  the  inunctions  himself,  or  the  professional 
rubber  may  be  employed.  Another  method  of  inunction  consists  in  wearing 
a  piece  of  flannel  cloth  on  which  mercurial  ointment  has  been  smeared 
(Teale).  This  is  bandaged  in  position,  and  its  location  changed  from 
time  to  time  as  signs  of  irritation  appear. 

The  hypodermic  (intramuscular)  use  of  mercury  is  occasionally  re- 
sorted to,  if  a  prompt  effect  is  recpired,  the  use  of  mercury  by  the 
mouth  impossible,  or  the  inunction  method  undesirable.  Indeed,  this 
method  may  often  be  employed  in  obstinate  forms  of  palmar  and  plantar 
syphihdes  in  which  the  other  methods  prove  unavailing.  The  best  preparation 
is  the  salicylate  of  mercury,  twenty-four  grains  of  which  are  mixed  with  one 
ounce  of  benzoinol.  Thirty  minims  of  this  mixture,  equal  to  one  and  a  half 
grains  of  mercury,  are  injected  twice  a  week  in  the  upper  and  outer  part  of 
the  buttock  (Keyes),  an  extra  long  needle  being  employed  in  order  to 
reach  the  gluteal  muscles.  The  mixture  should  be  well  shaken  before  use, 
and  the  needle  should  be  of  extra  large  caliber  in  order  to  prevent  clogging 
by  the  insoluble  particles  of  the  salicylate. 

The  occurrence  of  salivation  is  rare  in  properly  conducted  cases.  The 
nearest  approach  to  this  in  cases  in  which  the  progress  of  the  disease  is  care- 
fully watched  and  the  dose  of  mercury  properly  adapted  to  its  needs  is  the 
so-called  "touching "  of  the  gums  as  the  full  dose  of  the  drug  is  reached.  Should 
it  be  necessary  to  continue  the  latter,  there  is  danger  of  salivation,  and  pre- 
cautions should  be  taken  to  prevent  this.  These  consist  in  a  proper  care  of 
the  mouth,  as  to  cleanliness,  etc.,  and  the  avoidance  of  acids  in  the  dietary. 
The  further  preventive  treatment  of  salivation  consists  in  the  free  employ- 
ment of  baths  and  of  diuretics,  which  encourages  the  elimination  of  mercury 
from  the  system.     Chlorate  of  potassium  in  2  or  3  grain  doses  repeated  hourly. 


SYPHILIS  203 

given  in  a  demulcent,  such  as  flaxseed  or  slippery  elm  l)ark  tea,  exercises  a 
soothins;  inflnonco  on  tlio  mucous  membrane  of  the  mouth. 

\\'itli  the  full  (Icxc'lopniont  of  sahvation  the  breath  hoconies  highly  offen- 
sive, tlie  tongue  at  first  coated  and  then  swollen,  the  gums  puffed,  spongy  and 
bleeding,  and  deej)  red  or  bluisli  in  color.  A  profuse  flow  of  saliva  occurs. 
Symptoms  of  gastric  irritation  supervene;  diarrhea  is  present.  The  general 
adynamic  condition  is  marked  and  the  patient  becomes  mentally  depressed. 
In  the  final  stage  ulceration  of  the  inflamed  mucous  membrane  and  sometimes 
gangrenous  conditions  occur,  the  teeth  loosen  and  may  fall  out,  and  necrosis 
of  the  adjacent  bou}-  parts  takes  place.  Under  these  circumstances  a  mouth- 
wash consisting  of  a  1.5  to  2  per  cent  solution  of  carbolic  acid,  in  which  chlorate 
of  potassium  is  dissolved  in  the  proportion  of  15  grains  to  the  ounce,  should  l^e 
constantly  used.     Mixtures  of  borax  and  honey  are  also  useful. 

For  the  so-called  tertiary  symptoms  of  syphilis,  or  the  late  manifestations 
of  the  disease  due  to  gummatous  lesions,  the  treatment  is  the  combined  use  of 
mercury  and  iodid  of  potassium  (mixed  treatment),  which  should  be  alternated, 
as  the  effects  of  the  mercury  become  evident,  with  the  iodid  alone.  The  latter 
should  be  given  in  doses  of  from  5  to  100  grams  three  times  a  day,  according 
to  the  urgency  of  the  sj'-mptoms  and  the  toleration  of  the  drug.  It  must  l^e 
given  in  sufficiently  large  quantities  of  Vichy  or  hot  milk  to  insure  toleration 
by  the  stomach  (from  an  ounce  to  half  a  pint,  according  to  the  dose  of  the 
iodid  reached).  In  cases  in  which  the  iodid  of  potassium  is  not  well  borne,  or, 
because  of  the  large  quantity  of  fluid  necessary  as  the  massive  doses  are  reached, 
I  have  employed  wdth  satisfaction  the  preparation  of  iodin  known  as  iodonu- 
cleoid.  This  is  nonirritating  to  the  digestive  tract  when  given  in  powder  or 
tablet  form,  and  may  be  combined  with  mercuric  chlorid,  iron,  strychnin,  etc. 
The  dose  is  the  same  as  that  of  iodid  of  potassium. 

Syphilitic  Reinfection. — One  of  the  points  upon  which  is  based  the  belief 
of  the  curability  of  syphilis  is  the  undoubted  fact  that  the  disease  has  been 
acquired  a  second  time,  the  patient  passing  through  its  different  stages  twice. 
Inasmuch  as  the  existence  of  the  disease  renders  the  patient  absolutely  immune 
from  reinfection,  as  shown  by  numberless  experiments,  if  reinfection  occurs 
in  the  case  of  a  patient  who  beyond  question  has  suffered  from  the  disease, 
the  natural  conclusion  is  that  he  had  been  cured  of  the  disease. 

Hereditary  Syphilis. — In  this  form  of  the  disease  the  infection  is  derived 
from  one  or  both  parents,  subjects  of  the  disease  in  its  active  form.  The 
chancre  is  absent,  the  disease  usually  exhibiting  general  manifestations  from 
the  commencement.  When  active  infection  unmodified  l^y  treatment  exists  in 
both  parents,  or  in  the  mother  alone,  the  child  is  almost  certain  to  be  diseased. 
On  the  other  hand,  when  the  mother  is  healthy  and  the  father  alone  is  a  syph- 
ilitic, the  child  may  or  may  not  be  born  a  victim  of  the  disease.  The  possibility 
of  the  transmission  of  syphilis  to  the  child  m  utero,  particularly  in  the  later  stages 
of  gestation,  is  doubted  by  many  eminent  syphilographers.  If  the  chancre  is 
acquired  by  the  mother  simultaneously  with  the  occurrence  of  conception, 
she  usually  aborts.  It  is  generally  agreed  that  if  the  chancre  is  acquired  by 
the  mother  after  the  seventh  month  of  pregnancy  the  child  is  safe.  To  this 
rule,  however,  there  are  exceptions.  As  to  the  possibilities  of  infection, 
however,  in  the  intermediate  period,  authorities  are  not  agreed.  It  is  more 
than   probable  that  if  the  mother  acquires  a  chancre  at  any  time  between 


204  THE    CHRONIC  SURGICAL   INFECTIONS 

the  time  of  conception  and  the  seventh  month  of  gestation  the  child  will  be 
syphilitic. 

The  question  of  the  infection  of  the  mother  through  the  presence  in  utero 
of  the  product  of  conception  derived  from  a  syphilitic  father  {choc  en  retour  of 
R  i  c  o  r  d)  is  of  interest  in  this  connection.  That  this  may  occur  is  very 
probable,  since  it  is  more  than  hkely  that  the  ovum  becomes  diseased  through 
the  spermatozoa,  and  that  therefore  the  prolonged  presence  of  the  product  of 
such  a  conception  in  the  uterus  may  poison  the  mother.  The  experiment  of 
attempting  to  inoculate  an  apparently  healthy  woman  delivered  of  a  syphilitic 
child  conceived  of  a  syphilitic  father  resulted  negatively  (C  a  s  p  a  r  y).  This 
observation  supports  Colles'  law,  namely,  that  a  nursing  mother  never  accjuires 
a  chancre  of  the  nipple  from  her  syphihtic  offspring.  Chancres  of  the  nipple, 
however,  are  acquired  by  previously  healthy  wet-nurses  from  suckling  syphilitic 
infants. 

The  virulence  of  the  infection  in  the  child  will  depend  on  whether  or  not  the 
mother  has  been  subjected  to  treatment  during  the  period  of  gestation  and  how 
much  treatment  she  has  received.  All  grades  of  virulence  or  of  modifications  of 
the  infection  by  treatment  are  observed,  from  the  still-born  child  or  one  born 
with  the  most  unmistakable  signs  of  congenital  syphilis  and  doomed  to  early 
death,  to  the  child  born  apparently  healthy,  but  developing  the  evidences  of 
the  disease  later  in  life.  Finally,  if  a  syphilitic  mother  has  been  under  proper 
treatment  for  two  or  more  years,  or  if  four  years  have  passed  by  with  or  without 
treatment,  she  may  give  birth  to  a  healthy  child.  The  presence  of  gummatous 
lesions  in  the  parents  is  not  inconsistent  with  the  production  of  offspring  free 
from  the  disease. 

The  symptoms  of  hereditary  syphilis  are  practically  the  same  as  those  of 
the  acquired  form  of  the  disease,  with  the  exception  of  the  chancre.  Some 
of  these,  however,  are  accentuated  in  a  peculiar  manner  in  well-marked  cases. 
The  syphihtic  dyscrasia  is  manifested  in  the  small  and  puny  body,  the  wrinkled 
skin  and  the  pinched  face  (the  "old  man  countenance  ").  Deformities  of  a 
varied  character  may  be  present.  The  macular  syphilide  and  mucous  patches 
about  the  anus  and  mouth  are  frequently  observed  at  birth.  Gummatous 
lesions  in  the  viscera  are  not  uncommon.  In  cases  in  which  the  virus  has  been 
modified  by  treatment  during  gestation  the  signs  of  inherited  syphihs  are  not 
so  marked,  and  the  first  suspicion  of  the  existence  of  the  disease  may  be 
awakened  by  the  occurrence  of  digestive  or  nutritive  disturbances,  with  the 
appearance,  later  on,  of  rachitic  conditions,  diseases  of  the  bones  and  joints, 
lymphatic  glandular  enlargements,  corneal  lesions  (keratitis),  and  skin  affec- 
tions. Thinning  of  the  walls  of  the  skull  (syphilitic  craniotabes)  and  thick- 
ening of  the  ends  of  the  bones  at  the  epiphysial  fine  (syphilitic  osteochondritis) 
may  be  present.  The  so-called  Hutchinson  teeth,  generally  considered  as 
pathognomonic  of  congenital  syphilis,  consist  of  a  narrowing  and  notched  con- 
dition of  the  two  upper  central  incisors. 

The  treatment  of  congenital  syphihs  is  by  inunction.  Mercurial  ointment, 
made  in  half  strength,  should  be  used.  A  flannel  belly-band,  in  which  the 
ointment  is  well  incorporated,  should  be  worn  twelve  hours  out  of  the  twenty- 
four.  The  nutrition  should  be  maintained  at  the  very  highest  possible  point, 
and  as  soon  as  the  digestive  apparatus  will  permit  tonics,  iron  and  cod-liver  oil 
should  be  administered  in  addition. 


TUBERCULOSIS 


205 


TUBERCULOSIS 

]W  this  term  is  meant  tissue  changes  associated  witli  the  presence  of  the 
tubercle  bacillus.  The  latter  is  the  sole  cause  of  tuberculosis  (Koch), 
though  it  is  not  always  possible  to  demonstrate  its  presence  in  a  tul^erculous 
focus!  a  fact  readily  explained  by  the  biologic  characteristics  of  the  tuljercle 
bacillus.     (For  description  of  the  tubercle  bacillus,  see  page  30.) 

Of  late  the  bacillary  nature  of  the  factor  of  tuberculosis  has  been  called  into 
question  through  the  "demonstration  of  its  polymorphous  nature  (X  o  c  a  r  d 
and  R  o  u  X  ,  M  e  t  c  h  n  i  k  o  f  f ,,  and  others),  so  that  it  is  now  classed  among 
the  hvphomvcetes  (streptothrix,  K  r  use).  Under  certain  circumstances  the 
localization  and  propagation  of  the  tubercle  bacillus  in  the  living  body  resemble 
those  of  the  actinomyces  (Babes  and  L  e  v  a  d  i  t  i).  The  numerous  chnical 
similarities  of  tuberculosis  and  actinomycosis  can  be  readily  understood  through 
this  biologic  similarity. 

The  toxins  produced  by  the  tubercle  bacillus  are  not  yet  clearly  under- 
stood. The  disproportion  between  the  number  of  bacilli  and  the  magnitude 
of  the  tissue  changes  induces  the  belief  that  there  are  specific  bodies  pro- 
duced by  the  bacilli  which  are  capable  of  causing  profound  alterations.  In 
addition  to  the  effects  of  the  toxins  it  is  possible  that  chemic  combin- 
ations are  produced  in  the  infected  animal  or  human  economy  which  are 
the  result  of  tissue  necrosis  caused  by  the  tubercle  bacillus,  and  which  vary 
in  quantity  and  toxicity  according  to  the  constitutional  or  hereditary  charac- 
teristics of  the  individual.  The  complex  of  symptoms  known  as  tubercu- 
lous  cachexia    is.   to    a    certain  extent,  the  result  of  the  action   of  these 

toxins.  1      ■   r      • 

Clinically  it  is  difficult  to  locate  the  point  of  entrance  of  the  mfection  ni 
individual  cases,  though  numerous  anatomic  and  experimental  studies  have 
clearly  demonstrated  the  mode  of  entrance  and  the  paths  taken  by  the  infection. 
The  disease  travels  at  first  from  the  point  of  infection  by  means  of  the 
lymph-channels;  later  on,  and  especially  in  the  case  of  infection  of  more  distant 
organs,  the  blood-vessels  must  be  regarded  as  conveying  the  disease  (K  1  e  b  s). 
In  this  wav  the  cervical  glands  form  the  first  point  of  arrest  for  bacUli  entering 
by  way  of  the  mucous  membrane  of  the  mouth,  the  mesenteric  glands  the  first 
point  in  intestinal  infection,  etc.  The  bronchial  glands  are  infected  through 
the  lymphatics  before  the  lungs  necessarily  become  diseased.  In  all  probability 
most  forms  of  surgical  tuberculosis  (bones,  joints,  epididymis,  etc.,  as  well  as 
visceral  tuberculosis)  proceed  from  a  hematogenous  infection  (K  6  n  i  g),  though 
in  manv  instances  the  primary  focus  cannot  be  determined.  In  many 
cases  the  introduction  of  the  bacilli  into  the  blood  occurs  in  connection  with 
a  focus  in  juxtaposition  with  blood-vessels  of  small  caliber  into  which  perfora- 
tion may  occur  (W  e  i  g  e  r  t  ,  O  r  t  h  ,  X  a  s  s  e),  or  the  transition  into  the 
blood-current  is  accomplished  by  means  of  the  lymphatics  (B  a  u  m  g  a  r  t  e  n). 
As  a  third  source  of  hematogenous  infection  is  to  be  considered  a  primary 
disease  of  the  intima  (tuberculous  endangeitis)  (0  r  t  h  ,  S  i  g  g  ,  Strobe, 
Bend  a).  According  to  H  i  1  d  e  b  r  a  n  d  ,  this  may  result  either  from  the 
transportation  of  an  infectious  embolus  to  some  point  where  complete  stenosis 
of  the  vessel  does  not  occur  from  its  arrest,  as,  for  instance,  at  some  point  of 
bifurcation,  tuberculous  infection  of  the  wall  of  the  blood-vessel  following,  or 


206  THE    CHRONIC    SURGICAL   INFECTIONS 

from  the  entrance  into  the  blood-current  of  only  comparatively  few  bacilli 
which  are  deposited  on  the  vessel  wall,  causing  an  infection  at  one  or  more 
places. 

The  bacilli  first  develop  at  the  point  of  infection,  and  are  carried  from  there 
through  the  lymphatics  to  the  neighboring  tissues;  then  to  the  lymph-glands, 
and  through  these  eventually  to  other  points  of  the  body.  Unlike  the  point 
from  which  the  infection  of  acquired  syphilis  gains  entrance  into  the  organism, 
the  site  of  infection  in  tuberculosis  does  not  necessarily  involve  either  a  demon- 
strable tissue  defect  or  a  tuberculous  lesion ;  even  microscopically  there  may 
be  no  tuberculous  change.  Animals  fed  on  tuberculous  material  developed 
tuberculosis  of  the  mesenteric  glands  more  readily  than  a  tuberculosis  of  the 
intestines  themselves. 

Pathologic  Anatomy .^ — The  irritation  of  the  tubercle  bacillus  causes  first 
a  karyokinesis  of  the  fixed  cehs  (J  .  A  r  n  o  1  d),  the  connective-tissue  cells 
and  the  living  endothelium  of  the  vessels,  these  changes  occurring  first  in  the 
cells  inclosing  bacilli  (B  a  u  m  g  a  r  t  e  n  and  others).  The  tubercle  bacillus 
is  mostly  found  lying  in  the  interstitial  connective  tissue,  singly  or  in  pairs,  or 
in  small  or  even  large  colonies. 

The  further  changes  which  occur  in  the  infected  area  consist  of  swelling  of 
the  connective  tissue  and  endothelial  cells ;  according  to  V  i  r  c  h  o  w  ,  it  is 
the  latter  which  are  characteristic  in  the  formation  of  a  tubercle.  The  fibrous 
interstitial  tissue  thus  formed  is  gradually  absorbed  through  pressure  from  the 
proliferating  cells  until  only  a  small  reticulum  (the  fibrillary  basement  mem- 
i3rane)  is  left.  The  blood-vessels  within  the  infected  area  become  obliterated 
from  the  proliferation  of  their  OT\m  epithelium,  and  the  site  of  the  disease 
appears  surrounded  with  a  wall  of  epithelial  cells  showing  centrally  two, 
three,  or  many  nuclei;  this  constitutes  the  transition  stage  to  giant-cells. 
With  the  segmentation  of  the  nucleus  before  cell  division  actually  takes  place, 
the  development  of  the  cells  ceases  (V  i  r  c  h  o  w  ,   F  1  e  m  m  i  n  g). 

The  diminution  of  the  vitality  of  the  connective-tissue  cells  and  the  pro- 
gressive development  of  the  giant-cells  go  hand  in  hand,  and  the  latter  becomes 
the  precursor  of  the  changes  known  as  tissue  necrosis  and  cheesy  degeneration. 
The  genesis  of  the  giant-cells  at  the  present  time  is  unknown;  Orth  has 
shown,  however,  that  the  number  of  these  cells  is  in  inverse  ratio  to  the 
extent  and  intensity  of  the  infection,  so  that  the  observer  is  enabled  to 
estimate,  with  certain  limitations,  the  present  state  of  the  infection. 

According  to  the  degree  of  cellular  attraction  exerted  by  the  tubercle  as  a 
whole,  and  the  bacilh  in  particular  (positive  chemotaxis),  a  more  or  less  marked 
diapedesis  of  lymphoid  cells  from  the  surrounding  blood-vessels  occurs.  This 
takes  place  coincidentally  with  the  occurrence  of  fibrin  in  the  tubercle  (0  r  t  h), 
though  to  this  rule  there  are  exceptions.  Destructive  processes  now  super- 
vene. The  tissue  metamorphosis  is  terminated  by  either  a  slow  or  a 
rapidly  spreading  cell  death;  the  lymphoid  cells  shrink,  the  nuclei  disappear 
from  the  epithelioid  cells,  and  the  tubercle  tissue  breaks  up  in  a  finely  granular 
detritus  consisting  of  albumin  and  fat  globules.  Finally,  cheesy  degeneration 
occurs,  and  proceeds  from  the  center  to  the  periphery.  In  this  way  cavities 
are  formed.  Precisely  the  same  series  of  changes  takes  place,  whether  the 
lungs,  bones,  lymph-glands,  kidneys,  etc.,  are  attacked,  the  process  differing 
only  in  extent  and  virulence.     In  the  neighborhood  of  free  surfaces  or  cavities, 


TUBERCULOSIS  207 

such,  for  instance,  as  the  skin,  cavities  lined  with  mucous  membrane,  the  joints 
and  vessels,  a  destruction  of  the  covering  membrane  occurs  secondarily  to  the 
progressive  necrosis  of  the  adjacent  focus,  and  a  tuberculous  ulcer  results.  The 
peculiar  undermining  of  the  edges  of  these  tuberculous  ulcers  is  characteristic, 
and  tlcpcnds  on  the  power  of  the  enveloping  structure  surrounding  the  tissues 
to  resist  the  spread  of  the  tuberculous  process.  Exuberant  granulations  may 
bar  the  latter  and  assume  the  size  of  a  tumor  (tuberculous  granuloma),  or 
healing  may  take  place  by  cicatrization  of  the  focus. 

The  great  bulk  of  the  gummatous  mass  discharged  from  a  tuberculous  focus  is 
made  up  of  the  degenerated  tissue-cells ;  only  a  comparatively  small  part  con- 
sists of  leukocytes.  The  characteristic  features  of  tuberculous  granulations  are 
(1)  their  anemic  and  occasionally  cyanotic  appearance;  (2)  their  edematous 
condition  and  vitreous  luster;  (3)  their  proneness  to  break  down.  When  a 
tuberculous  focus  communicates  with  the  external  air  by  means  of  a  canal,  the 
latter  is  called  a  tuberculous  fistula.  Pending  the  definite  cicatrization  of  the 
central  focus  these  fistulas  may  repeatedly  break  open  again  after  healing. 
In  cases  in  which  spontaneous  cure  takes  place  this  occurs  either  by  separation 
and  elimination  from  the  system  .(sequestration)  of  the  tuberculous  products 
(granular  detritus,  degenerated  tissue-cells,  leukocytes  and  bacilli),  by  resorp- 
tion of  smaller  necrotic  foci,  or  by  encapsulation  and  cicatrization.  Encapsu- 
lated foci  sometimes  pass  into  a  further  stage  of  retrogressive  change,  namely, 
that  of  calcification. 

Small  bacillary  foci  may  remain  dormant  for  long  periods  of  time,  some- 
times for  several  years,  without  causing  any  subjective  or  clinically  objective 
symptoms  (latent  tuberculosis).  Either  of  their  own  accord  or  under  the 
influence  of  some  exciting  cause,  such,  for  instance,  as  the  presence  of  other 
infectious  diseases,  disorders  of  nutrition,  or  traumatism,  these  become  active, 
or  by  rupture  and  direct  discharge  into  the  circulation  alarming  symptoms 
from  new  bacillary  foci  are  produced.  The  importance  of  these  facts  and  their 
proper  recognition  relate  particularly  to  the  prognosis  of  the  disease.  Absolute 
cure  of  tuberculosis  cannot  take  place  until  all  bacilli  have  been  eliminated 
from  the  body  or  are  no  longer  viable. 

The  relation  between  traumatism  and  local  tuberculosis  frequently  becomes 
a  question  of  medicolegal  importance.  While  it  is  undoubtedly  true  that,  in  the 
large  majority  of  cases,  this  relation  does  not  exist,  still  the  possibility  of  its 
occurrence  demands  consideration.  If  a  patient  is  suffering  from  miliary 
tuberculosis,  with  baciUi  circulating  in  the  blood,  and  injury  is  inflicted  at  some 
part  of  the  body,  as  a  result  of  this  the  bacilli  are  deposited  at  the  site  of  the 
locus  minoris  resistentiae  and  give  rise  to  a  so-called  "local"  tuberculosis.  In 
this  instance  there  must  he  established  the  evidences  of  a  miliar}"  tuberculosis. 
Or  an  already  existing  tuberculous  focus  may  be  injured  simultaneously  with  a 
bone  or  joint,  as  a  result  of  which  fragments  of  tuberculous  material  are  carried 
directly  or  by  means  of  the  lymph-channels  into  the  blood-vessels  and  finally 
become  localized  at  the  site  of  the  bone  or  joint  injury.  Here  it  is  unlikely  that 
the  part  affected  by  the  injury  should  alone  be  selected  as  a  place  of  deposit  for 
the  tuberculous  tissue  w^hich  has  become  disintegrated  and  entered  the  circu- 
lation. Animal  experiments  have  shown  that  traumatism  does  not  favor  the 
localization  of  tuberculosis.  Finally,  an  old  latent  focus  may  exist  at  the  point 
affected  by  the  traumatism  and  again  become  active  through  the  circulatory 


20S  THE   CHRONIC    SURGICAL    INFECTIONS 

and  structural  changes  caused  hy  the  injury.  This  third  possibiUty  is  the  most 
hkely  of  all.  It  is  in  this  class  of  cases  particularly  that  a  positive  connection 
has  been  traced  between  tuberculosis  and  traumatism.  The  cases  in  Ciuestion, 
however,  must  be  few  and  isolated. 

Treatment  of  Surgical  Tuberculosis. — This  must  be  both  general  and 
local.  The  first  named  includes  dietetic  and  drug  treatment.  The  second 
is  subdivided  into  (a)  methods  to  increase  the  local  resistance  and  to  assist 
connective-tissue  proliferation;  (&)  methods  to  eliminate  or  destroy  the  bacilli. 

The  general  constitutional  treatment  is  of  the  greatest  importance  in  surgi- 
cal tuberculosis,  and  in  many  cases  may  overshadow^  all  other  methods.  Chief 
among  the  measures  imperatively  demanded  are  climate  and  altitude,  life  out 
of  doors  in  suital^le  weather  and  an  environment  with  plenty  of  sunlight  (sun 
parlor)  at  other  seasons  of  the  year,  a  suitable  mixed  diet,  cod-liver  oil  and  sea 
baths.  The  chief  benefit  to  be  derived  from  these  methods  of  treatment  is  in 
great  measure  due  to  increased  respiratory  movements,  increased  appetite,  etc. 
In  the  absence  of  opportunities  for  bathing  at  the  seashore,  home  baths  with  sea 
salt  may  be  employed.  These,  however,  are  less  satisfactory  than  batliing  in 
the  sea. 

Kapesser's  green  soap  treatment  consists  in  rubbing  the  patient  from 
the  neck  to  the  knees  with  green  soap  two  or  three  times  a  week,  preferably  in 
the  evening.  From  1  to  2  ounces  are  employed.  The  soap  is  washed  off  again 
with  warm  water  after  thirty  minutes.  The  method  has  been  found  of  great 
value,  although  its  rationale  is  not  clearly  understood. 

The  local  treatment  may  be  considered  under  three  groups:  (1)  local 
conservative  measures;  (2)  specific  antibacillary  treatment;  (3)  radical  opera- 
tive measures. 

First  among  the  local  conservative  measures  to  relieve  pain  and  to  facilitate 
cicatrization  is  to  be  mentioned  immobilization  of  the  parts  by  means  of 
plaster-of- Paris.  This  should  be  employed  wherever  applicable,  particularly 
in  tuberculous  affections  of  joints.  In  addition  to  the  effects  of  simple  im- 
mobilization, it  is  probable  that  the  pressure  of  the  bandage  likewise  brings 
about  more  or  less  pronounced  venous  stasis,  on  which  the  Bier  treat- 
ment is  based  (vide  infra). 

It  has  long  been  knowai  that  in  pulmonary  congestion,  such,  for  instance,  as 
occurs  from  certain  forms  of  cardiac  valvular  disease,  tuberculosis  rarely 
occurs,  and  when  present  tends  to  heal  in  the  presence  of  such  pulmonary  con- 
gestion (L  a  e  n  n  e  c  ,  R  o  k  i  t  a  n  s  k  y).  These  facts  led  to  the  introduction 
of  the  method  of  artificial  hyperemia  in  the  treatment  of  tuberculosis  of  the 
extremities  and  epididymis  (A  .  Bier).  The  first  effect  of  this  treatment  is 
the  almost  immecUate  relief  from  pain.  The  curative  results  are  to  be  ascribed 
partly  to  a  bactericidal  action  of  the  blood  itself,  and  partly  to .  the  in- 
creased proliferation  of  the  connective-tissue  cells.  The  most  brilliant  suc- 
cesses with  this  method  have  been  observed  in  cases  of  synovial  tuberculosis 
with  fungous  proliferation.  The  hyperemia  is  secured  by  means  of  thin  elastic 
bandages  placed  proximally  to  the  site  of  the  disease  in  such  a  manner  as  to 
obstruct  the  return  circulation  and  yet  not  interfere  with,  the  arterial  flow. 
The  limb  beyond  the  diseased  part  is  bandaged  with  a  roller  bandage  (Fig.  36). 
The  length  of  time  for  which  the  hyperemia  is  maintained  varies  in  different 
cases  from  two  to  three  hours  to  a  day  at  a  time.  The  method  must  be  modified 
for  individual  cases. 


ACTINOMYCOSIS 


209 


Among  the  conservative  measures  for  the  treatment  of  surgical  tuberculosis 
injections  into  the  tissues  and  joints  also  deserve  special  mention.  The  in- 
jections employed  up  to  the  present  time  have  been  supposed  to  exert  an  anti- 
bacillary  action.  The  drug  employed  most  extensivel}^  is  iodoform,  either 
a  10  {)er  cent  iodoform  glycerin  (B  r  u  n  s)  or  the  10  per  cent  olive  oil  mixture 
(T  r  e  n  d  e  1  e  n  b  u  r  g).  In  the  case  of  the  iodoform  glycerin,  the  marked 
action  of  the  glycerin  on  the  circulation,  causing  first  exudation  and 
then  resorption,  is  not  too  greatly  overestimated.  Even  in  the  case  of  the 
iodoform  itself,  the  7nodus  operandi  of  which  is  supposed  to  depend  on  the 
liberation  of  iodin,  it  is  now  believed  that  the  bactericidal  action  is  not  so 
important  as  its  action  on  the  tissues.  It  has  been  demonstrated  that,  under 
the     influence       of  iodoform,  fungous  granulations 

disappear  and    cell  '  proliferation  is  checked,  healthy 

vascular      granula-     L  ^  --"^^  -ijU^  ^^'^^^   tissue    taking    the    place 

of  the  fungous  gran-    mS^^^^--^^^^  ulations.      Tissue     containing 

tubercle   bacilli  be-    ImJ^^^^^v  comes  separated,  and  lastly  a 

marked     formation      ^^HL^    j^Uk^         *^^    connective     tissue  occurs, 
terminating incicat-  ^^%  ,m^^^Sl^m        rization      (Baumgarten, 

M  a  r  c  h  a  n  d  ,  P  . 
B  r  u  n  s  ,  N  a  u- 
w  e  r  k) .  The  5  per 
cent  iodin-potas- 
sium  iodid  injection 
(D  ur  ante)  is  ad- 
vocated b}^  some. 

PI       ,       ,  1  Fig.  36. — Bier's   Method    of   Securing   Temporary   Passive    Cox- 

noiornerapy  gestion    in    the    treatment  of  tuberculosis  of  a  Part. 

(F  i  n  s  e  n)  and  ra- 
diotherapy have  been  employed  in  tuberculous  diseases.  The  use  of  these 
measures  is  purely  empiric,  and  there  is  no  well-defined  theory  as  to  their  action. 
Radical  operative  measures  constitute  the  most  trustworthy  and  speedy 
method  of  dealing  with  surgical  tuberculosis,  whenever  the  focus  can  be  read- 
ily reached  and  removed  without  causing  serious  disturbance  of  function. 
The  benefit  to  the  general  health  which  almost  invariably  follows  the  prompt 
and  thorough  removal  of  the  tuberculous  tissue  is  marked  and  lasting. 


ACTINOMYCOSIS 

This  is  a  chronic  infectious  disease  which  occurs  in  domestic  animals  and 
man  and  is  caused  by  the  ray  fungus  (Actinomyces  bovis,  H  a  r  z). 

Bollinger,  of  iMunich,  in  1876,  first  demonstrated  the  fungoid  nature 
and  pathogenesis  of  the  just  visible,  yellowish,  and  more  or  less  opaque  granules 
characteristic  of  the  disease,  which  are  present  in  the  lesions,  in  the  contents  of 
bone  cavities,  and  in  the  discharge  from  fistulous  tracts.  These  granules, 
varying  in  size  from  0.15  to  0.75  mm.  in  diameter,  were  regularly  found 
in  the  central  softened  area  of  new  growths  of  the  jaw  and  tongue  of 
cattle,  popularly  known  as  "lumpy  jaw,"  which  had  previously  been  regarded 
either  as  one  of  the  forms  of  sarcoma  or  as  tuberculosis.  In  the  earlier  stages 
of  their  development  the  granules  are  of  the  consistency  of  soft  jell}',  and  of  a 
grayish-white  color.  Later  on  they  become  more  opaque  and  yellow,  and  finally, 
particularlv  in  cattle,  the  granule  mav  be  the  seat  of  a  deposit  of  cal- 
ls 


210  THE   CHRONIC    SURGICAL    INFECTIONS 

cium  salts  (mulberry like  granules).  The  botanist  Harz  found  that  the 
granules  were  made  up  of  several  patches  and  suspected  that  they  represented 
the  conidia  form  of  a  mold.  The  latter  grows  on  the  foodstuff  of  cattle,  the 
infection  taking  place  through  the  fodder.  It  is  usually  forced  into  the  tissues 
by  means  of  a  foreign  body.  The  parasite  is  identical  in  man  and  beast  (W  e  i  - 
g  e  r  t ,   P  o  n  f  i  c  k). 

The  fungus  belongs  in  the  same  provisional  group  as  the  hyphomycetes, 
and  is  in  intimate  relation  with  the  newer  findings  in  the  group  of  the  tubercle 
bacillus  (branching  ray  and  club  formation,  F  r  i  e  d  e  r  i  c  h  ,  L  e  v  a  d  i  t  i), 
to  which  it  bears  a  close  resemblance  in  its  effects  on  the  tissues. 

At  first  the  granules  consist  of  fine  threads;  later  on  these  increase  in  thick- 
ness, become  bulbous  at  their  extremities  (club-shaped  or  finger-shaped),  and 
are  arranged  radially  at  the  margins  of  the  hyaline  mass  in  which  the  threads 
occur.  Masses  of  pus-cells  are  also  present  and  make  up  a  portion  of  the  bulk  of 
the  granules. 

The  fungoid  patches  contain  threadlike  branching  mycelia  of  from  ^  to  1  /J. 
in  diameter  and  from  1  to  6  //  in  length,  with  a  membrane  which  takes  the 
anilin  dyes  but  does  not  stain  with  methylene-blue.  Simple  double  staining 
with  hematoxylin  and  eosin,  or  by  the  method  of  Weigert  or  of  Gram, 
is  efficient.  The  mycelium  is  normally  homogeneous;  it  is  sometimes  broken 
up  into  short  or  long  rods  and  sometimes  into  bodies  resembling  cocci.  In 
addition,  cocci  are  present.  These  are  sometimes  arranged  in  rows,  and  at 
other  times  irregularly  in  the  membrane.  They  are  to  be  considered  spores, 
since  by  growth  from  one  or  both  ends  true  mycelia  are  formed.  These  spores, 
and  perhaps  the  threadlike  fragments  as  well,  are  the  disseminators  of  the  dis- 
ease. Hyphae  with  regular  segmentation  are  formed  in  conidia  spores  in  cul- 
tures only  under  the  most  favorable  conditions.  In  the  body,  however,  the 
ends  of  the  mycelia  usually,  though  not  always,  undergo  degeneration,  the 
membrane  becoming  gelatinous,  so  that  the  club  shapes  and  pear  shapes  mani- 
fested on  staining  result.  By  rupture  of  the  membrane  finger  forms  occur. 
The  radiating  mycelia  with  the  peripheral  clubs  make  up  the  typic  felt  like 
patch  of  the  fungus.  After  death  of  the  fungus  the  club  shapes  may  persist 
and  may  be  found  embedded  in  the  cicatrix. 

Pathologic  Anatomy. — The  living  fungus  brings  about  changes  in  the 
tissues  not  unlike  those  produced  by  the  tubercle  bacillus.  It  becomes  sur- 
rounded by  round  and  eosinophile  granules,  and  beyond  these  by  granulation 
tissue  frequently  containing  giant  cells.  The  tubercle-like  mass  thus  developed 
is  made  up  of  round  and  ei^ithelioid  cells;  this  tubercle,  however,  does  not 
undergo  cheesy  but  hyaline  or  fatty  degeneration.  Fusion  of  two  or  more 
neighboring  tubercles  forms  suppurating  masses  or  abscess  cavities;  in  this 
suppurative  process  no  tissue  is  spared.  Only  in  parenchymatous  or  very 
vascular  organs  an  indurated  area  surrounds  the  connective-tissue  processes. 
In  connective  tissue,  however,  the  breaking  down  process  goes  on  more  rapidly 
and  easily. 

The  large  amount  of  inflammator}^  tissue  which  forms  a  thick,  tough, 
brawny  infiltration  in  connection  with  the  lesions  is  a  special  characteristic 
of  the  presence  of  this  fungus.  This  is  due  to  the  irritation  kept  up  by  the  para- 
site as  a  foreign  body,  as  well  as  to  the  cell-destroying  products  of  its  metabo- 
lism.    The   granulation    tissue   is   always   marked   by  great  vascularity  and 


ACTINOMYCOSIS  211 

UMidi'iicy  to  (Ict^X'iK'ration.  Tlio  yellow  color  is  .sometimes  present  in  the  granu- 
lations. A\'hen  infection  takes  place  in  subcutaneous  areas,  not  infrequently 
small  yellow  nuiltii)le  foci  may  be  cliscerned  through  the  intact  epidermis. 
Clinically,  however,  only  the  actual  identification  of  the  fungus  is  of  value  in 
differentiating  the  lesions  from  those  of  tuberculosis  and  carcinoma.  Mixed 
infections  (streptococci  and  staphylococci)  are  not  rare,  these  giving  rise  to 
marked  fever.  The  central  portion  of  the  focus  usually  contains  the  fungus, 
where  its  presence  may  be  detected  by  microscopic  examination.  It  may  be 
free  or  attached  to  the  foreign  body  by  means  of  which  it  gained  access. 

Symptoms. — Actinomycosis  is  essentially  a  chronic  disease,  lasting  for 
months  or  years.  Clinically,  the  cases  may  be  divided  into  those  occurring  in 
the  region  of  the  head,  the  thoracic  region,  the  abdominal  region  and  the  skin. 

The  Region  of  the  Head. — In  accordance  with  the  usual  mode  of  infection, 
namely,  through  the  medium  of  foodstuffs,  such  as  grain,  etc.,  actinomycosis 
occurs  most  frequently  in  the  neighborhood  of  the  mouth. .  The  infection 
spreads  from  the  oral  cavity  by  penetrating  the  mucous  membrane  of  the  gums, 
sometimes  through  the  cavities  of  carious  teeth,  and  extends  to  the  jaws  and 
soft  parts  of  the  neck.  Involvement  of  the  tongue  is  rare  either  primarily  or 
secondarily.  In  cattle  the  penetration  takes  place  between  a  tooth  and 
its  alveolus. 

Swelling  of  one  side  of  the  face  or  an  enlargement  of  the  jaw  ("lumpy 
jaw")  usually  occurs.  This  enlargement  is  most  readily  distinguished 
inside  the  mouth,  where  several  fistulous  tracts  are  also  usually  present, 
the  discharge  from  which  often  contains  the  yellow,  sulfurlike  detritus 
characteristic  of  the  disease.  Tenderness  on  pressure  is  sometimes  present, 
though  pronounced  pain  is  rare.  Except  in  cases  of  mixed  infection  {vide 
supra),  as  a  rule  fever  is  absent.  The  tendency  is  always  to  progressive  ex- 
tension of  the  infection,  the  routes  taken  being  in  the  direction  of  the  soft 
parts  of  the  neck,  the  pharynx,  the  vertebrae,  the  thoracic  organs,  and  the 
gastrointestinal  canal.  In  cases  of  infection  of  the  upper  jaw  there  frequently 
occurs  by  extension  actinomycosis  of  the  base  of  the  skull  and  of  the  brain. 
Retropharyngeal  and  spinal  cord  involvement  has  been  observed.  The  lacrimal 
canal  and  eyelids  may  be  involved. 

The  Thoracic  Region. — Involvement  of  the  pulmonary  organs  may  be 
either  primary  when  due  to  inoculation  by  inhalation,  or  secondary  when  due 
to  lesions  about  the  lower  jaw,  more  frequently  the  former.  All  the  symp- 
toms of  a  chronic  pulmonary  affection  are  present,  namely,  cough,  mu- 
copurulent expectoration,  fever,  and  progressive  emaciation.  According  to 
H  o  d  e  n  p  y  1 ,  either  the  mucous  membrane  of  the  bronchial  tubes  may  be 
involved,  giving  rise  to  symptoms  of  chronic  bronchitis,  or  interstitial 
,  changes  and  abscess  formation  may  occur  with  symptoms  of  bronchopneu- 
monia. Finally,  miliary  invasion  of  the  lungs  may  take  place,  the  s}'mptoms 
of  which  closely  resemble  those  of  miliary  tuberculosis.  Actinomycosis  of 
the  lungs  is  frequently  mistaken  for  pulmonary  tuberculosis.  Extension 
within  the  thorax  by  way  of  the  pharynx  and  esophagus  has  been  noticed. 
Primary  invasion  of  the  mammary  region  has  also  been  observed. 

The  Abdominal  Region. — Here  the  gastrointestinal  canal  is  primarily 
involved,  the  actinomyces  gaining  access  to  the  stomach  and  intestines  along 
with  the  food  and  resisting  the  destructive  effects  of  the  gastric  juice  and  bile. 


212  THE   CHRONIC    SURGICAL    INFECTIONS 

^rho  mucous  membrane  is  penetrated  and  the  submucous  comiectivc  tissue 
invaded,  after  which  the  mucosa  may  become  involved  to  a  superficial  extent, 
or  apparently  escape  entirely,  the  characteristic  destructive  jjrocess  going 
on  in  the  deeper  structures.  In  the  case  of  the  intestine  a  small  submucous 
tubercle  appears  which  breaks  down  in  the  center  and  gives  rise  to  a  small 
ulcer.  Exceptionally  the  latter  may  heal,  leaving  a  pigmented  and  irregular 
cicatrix.  The  stomach  and  all  portions  of  the  small  and  large  intestine, 
including  the  vermiform  appendix,  may  be  the  seat  of  invasion.  About  one- 
half  of  the  cases  occur  primarily  in  either  the  cecum  or  the  appendix.  The 
liver  is  frequently  involved  secondarily.  Abscess  of  the  liver,  with  rupture 
into  the  cavity  of  the  chest,  may  occur.  Extension  posteriorly  leads  to  in- 
volvement of  the  spinal  column  and  invasion  of  the  spinal  canal;  general 
metastasis  may  occur.  The  destructive  process  may  extend  anteriorly  and 
externally  and  involve  the  abdominal  wall. 

The  onset  in  abdominal  actinomycosis  is  frequently  quite  sudden,  the 
symptoms  being  those  of  catarrhal  gastrointestinal  disturbances,  namely, 
vomiting  and  either  diarrhea  or  constipation.  Or  obscure  abdominal  pains 
may  be  present  for  weeks  or  months.  The  frequency  of  origin  in  the  cecal 
region  may  lead  to  the  diagnosis  of  chronic  recurring  or  chronic  relapsing 
appendicitis.  This  is  strengthened  by  the  later  appearance  of  a  tumor  in  this 
region.  Or,  a  tumor  finally  appears  in  the  neighborhood  of  the  umbilicus. 
In  any  case  the  tumor  presents  a  somewhat  irregular  outline.  Pain  is  usually 
present  at  this  stage.  With  involvement  of  the  anterior  abdominal  wall  the 
infiltrated  area  softens,  fistulous  openings  form,  and  the  surrounding  skin 
presents  a  peculiar  livid  hue,  described  by  some  authors  as  bluish- violet,  merg- 
ing into  a  bluish-gray  (slate  color)  toward  the  margins  of  the  infiltration. 

Actinomycosis  of  the  Skin. — There  are  trustworthy  observations  showing 
that  inoculations  of  the  skin  with  resulting  local  actinomycosis  may  take  place. 
This  may  occur  from  chaff  (Ammentorp,  Reboul),  from  splinters  of 
wood  in  the  case  of  farm  laborers  (E .  M  ii  1 1  e  r),  or  from  poultices  (W.  M  ii  1  - 
1  e  r).     The  lesions  closely  resemble  those  of  tuberculosis  of  the  skin. 

The  pyemia  of  actinomycotic  origin  presents  an  interesting  picture.  It 
constitutes  the  final  stage  of  the  chronic  afebrile  cases.  In  addition  to  the 
dissemination  among  the  internal  organs  there  occur  multiple  subcutaneous 
abscesses.  The  metastatic  abscesses  take  place  through  the  circulation. 
They  may  occur  through  rupture  of  a  primary  focus  into  a  large  vessel,  such,  for 
instance,  as  the  jugular  vein,  of  which  there  are  five  recorded  instances  (S  i  c  k), 
or,  the  disease  having  extended  from  the  lungs  or  intestine  to  the  liver,  the 
infection  is  transported  by  the  hepatic  vessels.  Dissemination  through  the 
lymph-vessels  does  not  take  place. 

Diagnosis. — The  diagnosis  depends  on  the  presence  of  the  character- 
istic granules  or  colonies  in  the  lesions  or  in  the  discharges  from  the  sinuses  lead- 
ing from  the  same.  These  are  not  always  discoverable  with  the  naked  eye ; 
it  is  necessary  to  subject  the  suspected  material  to  microscopic  examination 
in  order  to  distinguish  the  granules  or  colonies  from  necrotic  tissue  and  col- 
lections of  pus-cells,  for  which  they  may  be  mistaken.  In  pulmonary  actinomy- 
cosis the  fungus  will  be  found  in  the  sputum  or  in  the  discharges  from  fistulous 
tracts  in  the  chest  wall  leading  to  the  lesions.  In  examinations  of  the  sputum 
care  should  be  taken  to  differentiate  the  ray  fungus  from  the  common  lepto- 
thrix  of  the  mouth ;  the  filaments  of  the  latter  are  frequently  found  adherent  to 


ACTINOMYCOSIS  213 

epithelial  cells;  they  are  larger,  straighter,  and  thicker  than  those  of  the  former, 
and  they  do  not  branch,  as  do  tlie  filaments  of  the  ray  fungus. 

The  fact  that  dissemination  by  the  lymph-vessels  does  not  take  place  in 
actinoniA'cosis  should  be  borne  in  mind  as  an  aid  in  differentiating  the  disease. 
The  finding  of  the  fungus,  however,  is  the  only  positive  diagnostic  point.* 

Prognosis. — The  statistics  compiled  by  S  i  c  k  ,  of  Kiel,  are  exceedingly  in- 
teresting in  this  connection.  In  cases  in  which  extension  to  the  base  of  the  skull 
and  brain  took  place  this  complication  was  observed  six  times  out  of  61  cases  oc- 
curring primarily  in  the  upper  jaw,  and  ten  times  out  of  525  cases  occurring  pri- 
marily in  the  lower  jaw.  In  a  general  way,  cases  occurring  in  the  lower  jaw 
offer  a  more  favorable  prognosis  than  those  in  the  upper  jaw.  Of  the  525  cases 
above  mentioned,  aside  from  the  10  necessarily  fatal  cases  in  which  propagation 
to  the  brain  took  place,  4  proved  fatal  by  secondary  lung  invasion,  3  by  retro- 
pharyngeal abscess,  and  1  by  spinal  cord  involvement.  In  addition,  there 
was  1  fatal  abdominal  case  and  6  cases  of  general  actinomycosis.  Of  27  cases 
of  actinomycosis  of  the  tongue,  all  were  cured  b}^  operation.  The  prognosis 
is  equally  favorable  for  circumscribed  lip  and  cheek  cases.  Of  20  intrathoracic 
cases  of  pharyngoesophageal  origin,  19  proved  fatal.  Out  of  142  pulmonar}^ 
cases,  5  are  alleged  to  have  been  cured.  In  two  of  these  cases  the  diagnosis  was 
not  assured,  and  in  the  remaining,  periods  of  time  varying  from  six  months  to 
two  years  only  had  elapsed  between  the  commencement  of  the  symptoms  and 
the  date  of  the  report.  In  view  of  the  now  well-known  latency  of  the  pulmonary 
cases  which  finally  prove  fatal  this  is  manifestly  too  short  a  time  on  which  to 
base  a  statement  of  cure.  In  all  probability  the  affection  as  it  attacks  the  lungs 
is  an  irremediable  one,  death  taking  place  b}'  cachexia  and  metastasis  to  the  liver. 
In  abdominal  cases  the  prognosis  is  relatively  better,  especially  if  the  abdominal 
wall  is  involved  and  the  process  extends  anteriorly  and  outwardly.  In  ab- 
dominal cases  extending  posteriorly  death  takes  place  from  abscess  of  the  liver, 
rupture  into  the  lung  or  spinal  canal,  and  general  metastasis.  Invasions  of  the 
colon  proved  uniformly  fatal.  Ninety-three  cases  of  actinomycotic  appen- 
dicitis have  been  reported,  19  of  which  recovered.  The  rectum  was  involved 
in  13  cases,  7  of  which  proved  fatal.  In  a  total  of  214  abdominal  cases, 
only  47  recovered  ;  tliis  does  not  include  30  cases  which,  according  to  the 
original  report,  were  '^  recovering." 

In  rare  cases  there  is  a  tendency  to  spontaneous  cure.  Sick  asserts  that 
there  are  two  or  three  well-authenticated  cases  of  this  character. 

Treatment. — The  treatment  is  preferably  surgical  when  possible.  If 
the  foci  are  situated  where  they  can  be  safely  removed,  a  cure  may  be  confi- 
dently expected.  Where  complete  removal  cannot  be  effected,  and  this  is  the 
rule  rather  than  the  exception,  free  opening,  partial  excision,  and  the  iodid  of 
potassium  treatment  should  be  followed.  The  latter  is  used  in  a  10  per  cent 
solution  as  an  injection  into  the  surrounding  tissues,  and  internally  in  from  2 
to  3  dram  doses.  The  iodid  of  potassium  does  not  act  on  the  fungus,  but  on 
the  tissues  (Prue  z  ,  of  Konigsberg).  In  desperate  cases  arsenic  has  been 
of  value.  For  local  use  tincture  of  iodin,  nitrate  of  sih'er  in  stick  or  1  per  cent 
ointment,  boric  acid,  and  concentrated  alcohol  are  all  of  value.  As  in  tuber- 
culosis, climate  and  out-of-door  life  exercise  a  favorable  influence  over  the 
disease  (H  e  u  s  s  e  r). 

♦Reactions  following  tuberculin  injections  have  been  observed  bj-  Billroth,  Eiselberg, 
and  others. 


SECTION    VI 
TUMORS 

CLASSIFICATION 

The  etiology  of  tumors  is  unknown.  \'  i  r  c  h  o  w  has  shown,  however, 
that  all  the  tissues  in  these  new  growths  have  a  normal  histologic  prototype. 
Under  these  circumstances,  therefore,  the  most  natural  and  satisfactory 
method  of  classification  for  the  study  of  tumors  is  based  on  their  structural 
characteristics. 

The  term  tumor  may  be  applied  to  the  following  abnormal  conditions, 
arranged  in  four  groups : 

1.  Connective-tissue    growths,   or    tumors    of    connective-tissue    origin. 

2.  Epithelial  growths,  or  tumors  whose  essential  feature  is  the  presence 
of  epithelium. 

3.  Dermoids,  or  tumors  containing  skin  or  mucous  membrane  in  abnormal 
situations. 

4.  Cysts  differ  in  many  respects  from  tumors,  though  clinically  they 
possess  so  many  features  in  common  that  it  is  convenient  to  consider  them 
in  this  connection. 

If  the  methods  of  classification  of  the  zoologist  are  adopted,  it  may  be  said 
that  each  of  these  groups  contains  several  genera  and  that  each  genus  contains 
one  or  more  species  (Sutton). 

From  the  standpoint  of  the  practical  surgeon  the  effects  of  tumors  on  the 
individual  are  of  the  greatest  importance;  hence  it  is  usual  to  designate  them 
as  malignant  and  innocent. 

Malignant  Tumors. — Malignant  growths  possess  the  following  charac- 
teristics: (1)  they  infiltrate  the  surrounding  tissues;  (2)  they  infect  neigh- 
boring lymphatic  glands;  (3)  they  tend  to  recur  after  removal;  (4)  dissemi- 
nation takes  place  in  more  or  less  remote  organs;  (5)  in  their  natural  course  they 
inevitably  destroy  life.  The  two  genera  of  tumors  to  which  the  term  malignant 
is  applicable  are  the  sarcomas  and  the  carcinomas. 

Malignant  tumors,  wherever  situated,  tend  to  destroy  life.  The  extent  to 
which  dissemination  occurs  is  best  illustrated  in  cases  of  melanosarcoma,  in 
which  secondary  deposits  occur  in  almost  all  the  organs  of  the  body,  the  tumors 
in  the  skin  alone  being  sometimes  numbered  by  thousands.  The  most  decided 
examples  of  malignancy,  however,  are  observed  when  tumors  of  this  type 
occur  primarily  in  nonvital  organs  and  destroy  life  in  a  few  months.  Here 
death  is  due,  not  to  interference  with  the  function  of  the  organ  first  attacked, 
but  either  to  secondary  deposits  in  remote  and  vital  organs,  or  to  combined 
septic  and  anemic  conditions  (cachexia).  When  a  malignant  tumor  involves 
a  vital  organ,  life  is  often  destroyed  before  there  has  been  time  for  dissemina- 
tion to  take  place. 

Environment. — The  influences  of  environment  are  shown  in  the  familiar 

214 


CLASSIFICATION  215 

examples  of  cancer  of  the  larynx,  in  which  death  takes  place  from  suffocation 
or  from  septic  pneumonia  following  ulceration,  of  death  from  starvation  in 
cancer  of  the  gastric  orifices,  and  of  death  from  renal  disease  in  cancer  of  the 
prostate  with  m'iiiarv  obstruction.  The  environment  of  a  malignant  tumor  in  its 
relation  to  treatment  likewise  exercises  some  influence  on  the  life-destroying 
pro]ierties  of  the  tumor,  irrespective  of  the  importance  of  the  part  attacked  or 
the  genus  of  the  tumor.  For  instance,  a  periosteal  sarcoma  attacking  the 
femur  will,  on  recurrence,  destroy  life  almost  twelve  times  as  quickly  as  a  tumor 
with  the  same  histologic  characters  situated  on  the  tibia,  both  being  submitted 
to  amputation.  From  this  circumstance  Bland  Sutton  is  led  to  suspect 
that  variations  in  tissue  actually  constitute  an  altered  environment.  It  is 
much  more  prol)able,  however,  that  the  differences  in  this  instance  are  due 
to  increased  difficulties  of  relatively  complete  removal. 

i\Ialignant  tumors  rarely  occur  as  multiple  growths.  Exceptions  to  this 
are  found  in  sarcomas  occurring  in  paired  organs,  such  as  the  kidneys,  adrenals, 
ovaries,  and  retinae  of  young  children. 

A  malignant  tumor  may  arise  in  an  organ  already  occupied  by  an  innocent 
tumor,  such  as  occurs  when  a  carcinoma  attacks  the  endometrium  of  a  uterus, 
the  seat  of  a  fibroid.  Separate  organs  that  are  a  part  of  the  same  system 
msLY  be  attacked  concurrently  by  a  malignant  and  an  innocent  tumor,  as,  for 
instance,  in  the  case  of  a  mammary  carcinoma  and  on  ovarian  adenoma. 

Innocent  Tumors. — As  differing  from  the  malignant  type  of  tumors, 
innocent  tumors  present  the  following:  (1)  they  are  inclosed  in  a  capsule, 
as  a  rule,  and  when  not  so  inclosed  their  manner  of  increase  is  by  diffusion 
and  not  by  infiltration  or  implication  of  the  surrounding  tissues,  the  latter 
undergoing  no  change;  (2)  they  do  not  produce  infection  of  the  lymphatic 
glands;  (3)  there  is  no  recurrence  after  complete  removal;  (4)  dissemi- 
nation never  takes  place;  (5)  clanger  to  life  arises  only  from  mechanic  causes 
or  from  accidentally  produced  septic  conditions. 

Environment. — While  malignant  tumors  destroy  life  whatever  their  situa- 
tion, the  dangers  arising  from  innocent  tumors  depend  entirely  on  their 
environment  and  on  irritating  or  disturbing  conditions.  For  instance,  a  small 
nonmalignant  growth  situated  in  the  spinal  cord  may  cause  death  in  a  com- 
paratively short  time;  an  enlarged  thyroid  may  cause  sudden  and  fatal  suf- 
focation from  pressure  on  the  trachea  (scabbard  trachea) ;  or  a  lipoma  may 
become  accidentally  infected  through  a  point  of  irritation  arising  from  friction 
of  the  clothing. 

Innocent  tumors,  unlike  malignant  growths,  are  often  multiple.  There 
is  a  tendency  in  this  direction  in  all  benign  tumors  except  myelomas.  Two 
genera  of  innocent  tumors  maj^  present  themselves  simultaneously  in  the  same 
individual,  or  an  innocent  tumor  and  a  malignant  tumor  ma}'  appear  under  the 
same  circumstances.  An  innocent  tumor  may  precede  the  development  of  a 
malignant  tumor  in  the  same  organ  for  many  years.  Finally,  the  rarest  of  all 
combinations  is  the  presence  of  an  innocent  tumor  surrounded  by  a  malignant 
growth. 

Structure  of  Tumors. — The  usefulness  of  a  classification  of  tumors 
based  on  the  histologic  features  of  tumors  is  emphasized  by  the  fact  that  the 
histology  and  embryology  of  an  organ  point  with  comparative  certainty  to  the 
various  genera  of  tumors  and  cysts  to  which  it  is  subject.     Exceptions,  how- 


216  TUMORS 

ever,  are  to  be  noticed  in  the  liability  of  the  salivary  glands  to  pure  chondromas 
and  of  the  ovary  to  dermoids. 

CONNECTIVE-TISSUE   TUMORS 

The  various  genera  of  the  connective-tissue  group  of  tumors  are  included  in 
the  following:  (1)  lipomas;  (2)  chondromas;  (3)  osteomas;  (4)  odontomas; 
(5)  fibromas  and  myxomas;  (6)  myelomas;  (7)  sarcomas;  (8)  neuromas;  (9) 
angiomas;   (10)  lymphangiomas;   (11)  myomas. 

Lipomas. — A  lipoma  is  a  tumor  composed  of  fat.  The  genus  is  limited  to  a 
single  species.  Its  occurrence  is  more  generalized  than  that  of  any  other  genus 
occurring  in  man,  with  the  exception  of  sarcoma.  It  is  found  in  the  subcutane- 
ous and  subserous  tissues;  beneath  the  synovial  and  mucous  membranes;  in 
the  muscular  tissues  and  intermuscular  spaces;  as  parosteal  growths  and  in 
connection  with  the  sheaths  of  nerves  and  the  cerebral  and  spinal  meninges. 

Subcutaneous  Lipomas. — The  subcutaneous  fat  is  the  situation  in  which 
lipomas  are  most  commonly  found.  In  this  situation  they  are  irregularly 
lobulated,  encapsulated,  movable  within  the  capsule,  the  latter  being  more  or 
less  adherent  to  the  skin.  They  are  usually  single,  though  one  or  more  may 
be  found  in  different  situations  in  the  same  individual.  They  are  often  sym- 
metric and  tend  to  become  pedunculated.  They  vary  greatly  in  size,  from 
a  marble  to  a  man's  head.  Exceptionally  they  attain  an  enormous  size. 
They  are  confined  for  the  most  part  to  the  trunk  and  the  parts  immediately 
adjoining  the  same.  They  are  occasionally  found  on  the  hands  and  feet,  where 
they  are  liable  to  be  congenital.  They  are  more  frequent  in  the  former 
situation,  where  they  simulate  compound  ganglions.  Those  of  the  palm  probably 
originate  in  the  lobules  of  fat  lying  between  the  lumbricales.  They  may  occur 
in  a  vascular  form  on  the  face  (nevolipomas),  where  they  are  probably  nevi 
undergoing  cure  by  fatty  degeneration.  Calcification  may  occur  in  old  lipomas 
through  deposits  of  earthy  salts  in  the  fibrous  septa. 

Subserous  Lipomas. — These  occur  in  the  layer  of  fat  on  which  the  peri- 
toneum rests,  and  are  of  special  interest  to  the  surgeon,  from  the  fact  that  they 
are  likely  to  occur  in  the  subserous  fat  at  the  hernial  apertures  and  be  mistaken 
for  a  hernia.  They  may  actually  give  rise  to  hernia  by  protruding  into  the 
inguinal  or  femoral  canals  and  dragging  with  them  a  process  of  peritoneum. 
The  latter  may  subsequently  become  the  seat  of  hernial  contents.  Hernia  of 
the  bladder  is  particularly  liable  to  arise  in  this  manner.  Subserous  lipomas 
sometimes  appear  as  fatty  hernias  of  the  linea  alba,  near  the  umbilicus.  They 
may  grow  between  the  layers  of  the  mesometrium  and  simulate  ovarian  tumors. 

A  lipoma  having  its  origin  in  the  fat  behind  the  ensiform  cartilage  may 
occupy  the  lower  portion  of  the  anterior  mediastinum,  after  having  passed 
through  the  gap  in  the  diaphragm  in  this  locality.  The  subpleural  fat  is  some- 
times the  seat  of  a  lipoma  (R  o  k  i  t  a  n  s  k  y)  which  may  make  its  way  on  each 
side  of  the  chest  wall,  forming  an  intrathoracic  and  an  extrathoracic  portion 
(G  u  s  s  e  n  b  a  u  e  r). 

Submucous  Lipomas. — These  are  of  exceptionally  rare  occurrence.  They 
are  found  in  children  in  the  subconjunctival  fat;  on  the  hps;  in  the  larynx 
on  the  aryteno-epiglottic  fold  (Holt,  Sidney  Jones);  and  beneath 
the  gastric  and  intestinal  mucous  membrane. 

Subsynovial  Lipomas. — Those  occurring    in  the  knee-joint  are  of  the 


CLASSIFICATION 


217 


o-reate^t  surgical  importance.  Thev  occur  in  this  situation  most  commonly 
alongside  the  patella,  at  the  site  of  the  alar  ligaments.  The  so-called  lipoma 
arborescens  is  said  to  be  associated  with  rheumatoid  arthritis. 

Intermuscular  Lipomas.— The  largest  specimens  of  this  variety  are  found 
in  the  int(>rmuscular  strata  of  the  anterior  abdominal  wall.  They  are  also 
found  l)etween  the  pectoral  muscles,  and  between  the  muscles  of  the  tongue. 
The  so-called  "sucking  cushion/'  a  collection  of  fat  between  the  masseter  and 
the  buccinator  muscle,  has  been  considered  by  some  a  lipoma. 

Intramuscular  Lipomas.— These  have  been  found  in  the  deltoid,  biceps 
of  the  arm,  complexus,  and  rectus  abdominis  muscles.  They  have_  also 
been  reported  as  occurring  in  a  submucous  uterine  myoma   (J  .    Smith, 

Periosteal  Lipomas.— These  are  usually  congenital,  are  of  infrequent 
occurrence  and  have  been  found  in  almost  all  portions  of  the  skeleton.  They 
spring  from  the  periosteum  and  generally  contain  traces  of  striated  muscular 

"^Neurolipomas  is  a  term  applied  to  fatty  growths  springing  from  the  sheaths 
of  peripheral  nerves.     They  are  not  usually  diagnosed  until  after  removal. 

Meningeal  Lipomas.— These  are  found  both  within  the  spmal  dura  and 
outside  it,  between  the  layers  of  the  dura  at  the  base,  and  on  the  sac  of  the 
spina  bifida  in  the  lumbosacral  region.  _ 

The  Clinical  Features  of  Lipomas.— This  genus  of  tumor  is  usually  easily 
diao-nosed,  though  under  some  circumstances  the  diagnosis  may  be  exceedingly 
difficult  This  is  particularly  true  of  the  periosteal,  perineurial,  intramuscular, 
subserous,  and  meningeal  varieties.  In  operating  on  tumors  m  the  imddle 
line  of  the  back  special  care  must  be  taken  to  recognize  those  connected  with 

the  spinal  dura. 

Treatment.— Although  innocent  in  character,  these  tumors  are  not  without 
harmful  tendencies,  and  hence  many  of  them  will  require  ultimate  removal. 
When  single,  they  are  likely  to  attain  large  proportions ;  but  when  a  number  are 
present,  this  tendency  seems  to  be  absent.  When  so  situated  as  to  become 
irritated  by  the  clothing,  or  by  some  particular  occupation  of  the  patient, 
their  removal  should  be  strongly  advised. 

Chondromas.— These  are  tumors  composed  of  hyahne  cartilage,  ihe 
genus  contains  three  species,  viz.,  (1)  chondroma;  (2)  ecchondrosis;  (3)  loose 

cartilages  in  joints.  . 

Chondromas,  in  their  most  typic  condition,  occur  m  relation  to  the  epiphy- 
sial cartilages  of  the  long  bones  in  children  and  young  adults.  They  are  usually 
single,  but  may  be  multiple,  particularly  when  they  occur  m  the  hands  and  feet. 
They  are  always  encapsulated,  painless,  of  slow  growth,  and  firm  to  the  touch, 
except  when  they  have  undergone,  mucoid  degeneration.  They  may  undergo 
-  calcification  and  they  sometimes  ossify.  In  rickety  individuals  they  frequently 
occur  from  the  presence  of  fetal  cartilage  (V  i  r  c  h  o  w).  Their  occurrence  m 
the  parotid,  submaxillary,  salivary,  and  lacrimal  glands  constitutes  one  of  the 
most  striking  anomalies  in  connection  with  tumors. 

Small  local  outgrowths  of  cartilage  are  known  as  ecchondroses.  ihey 
occur  on  the  edges  of  articular  cartilages,  the  laryngeal  cartilages  and  the 
triangular  cartilage  of  the  nose.  They  are  specially  common  m  the  knee-joint 
after  the  age  of  forty,  and  have  been  thought  to  have  some  connection  with 
rheumatoid  arthritis.     They  occur  as  sessile  or  pedunculated  nodules,  which 


218  TUMORS 

may  become  detached  and  constitute  a  loose  body  in  the  joint  cavity;  or  they 
may  be  still  held  by  a  slight  fibrous  attachment. 

Laryngeal  ecchondroses  are  rare.  They  may  grow  from  any  of  the  laryn- 
geal cartilages,  most  frequently,  however,  from  the  posterior  plate  of  the  cricoid, 
though  both  surfaces  may  be  involved  and  the  cavity  of  the  larynx  encroached 
upon.  They  vary  in  size  from  a  pea  to  a  walnut.  Those  that  project  into 
the  cavity  of  the  larynx  are  covered  with  mucous  membrane,  which  in  excep- 
tional instances  becomes  ulcerated.  Intralaryngeal  projections  give  rise  to 
obstructed  breathing  and  aphonia. 

Ecchondroses  springing  from  the  triangular  cartilage  of  the  nose  are 
occasionally  observed,  the  treatment  of  which  by  removal  is  usually  advised. 

Loose  Cartilages. — Li  addition  to  the  detached  ecchondroses  already 
mentioned,  pieces  of  hyaline  cartilage  are  found  in  joints  attached  by  narrow 
pedicles,  or  lying  in  depressions,  from  which  they  may  become  detached  or 
dislodged.  They  vary  in  size  and  usually  occur  in  flat  discs.  They  may  be 
single  or  multiple,  and  sometimes  are  found  in  the  corresponding  joints  as  well. 
They  are  believed  to  have  their  origin  in  enlarged  synovial  villi  which  undergo 
chondrification.  Calcareous  changes  sometimes  occur.  The  latter  may  take 
place  without  chondrification,  or  both  changes  may  be  absent,  the  loose  body 
consisting  simply  of  the  enlarged  and  thickened  villi. 

The  treatment  of  chondromas  consists  in  incising  the  capsule  and  shelling 
out  the  cartilage.  When  a  large  number  are  present  on  the  bones  of  the 
fingers,  amputation  may  be  necessary.  Loose  bodies  constitute  one  of  the 
conditions  present  in  so-called  "internal  derangement  of  the  knee-joint,"  for 
which  arthrotomy  and  removal  of  the  loose  body  become  necessary.  As  a  rule, 
small  bodies  give  rise  to  more  trouble  than  the  larger  ones,  and  present 
greater  difficulties  of  removal  on  account  of  the  uncertainty  of  locating  them 
exactly  when  the  joint  is  opened. 

Osteomas. — These  consist  of  ossifying  chondromas,  the  growth  of  the 
osteoma  taking  place  from  the  covering  of  hyaline  cartilage  of  the  tumor,  pre- 
cisely as  the  growth  of  a  long  bone  takes  place  from  epiphysial  cartilage.  Two 
species  of  this  genus  are  recognized,  namely,  compact  osteomas  and  can- 
cellous osteomas. 

Compact  osteomas  are  identical  in  structure  with  the  tissue  forming  the 
shaft  of  a  long  bone.  Their  distribution  is  rather  general,  but  they  seem  to  occur 
by  preference  in  the  frontal  sinuses,  in  the  roof  of  the  orbit,  in  the  bony  walls 
of  the  external  auditory  meatus,  where  they  have  their  origin  in  the  numerous 
centers  for  cartilage  formation  in  that  neighborhood,  in  the  mastoid  process  and 
the  angle  of  the  jaw.  They  are  usually  sessile,  and  are  sometimes  composed  of 
dense  tissue  of  ivorylike  hardness.  Those  occurring  at  the  margin  of  the 
external  auditory  meatus  may  obstruct  the  latter  and  cause  impairment  of 
hearing. 

Cancellous  Osteomas. — These  resemble  the  cancellous  structure  of  bone 
and  usually  possess  a  thick  covering  of  hyaline  cartilage.  They  occur  generally 
in  sessile  growths,  though  they  are  occasionally  pedunculated.  They  are  of 
slow  growth,  but,  though  painless  and  benign  in  character,  they  may  in  time 
attain  a  size  sufficient  to  cause  pain  or  even  imperil  life  by  pressure  on  large 
trunks  or  important  organs.  They  are  often  congenital  and  by  some  have 
been  deemed  hereditary.     They  are  sometimes  multiple  and  may  develop 


CLASSIFICATION  219 

symmetrically  as  regards  situation  in  the  individual.  They  have  been  known 
to  attain  large  proportions  and  to  become  the  seat  of  sarcoma. 

Exostoses. — Although  these  are  not  true  bony  tumors,  l)ut  rather  bony 
outgrowths,  it  will  be  convenient  to  treat  of  them  in  this  connection.  They 
occur  as  exaggerations  of  the  normal  bony  projections  at  the  site  of  the 
attachment  of  tendons,  such,  for  instance,  as  the  adductor  tubercle.  This  form 
of  growth  is  frequently  found  in  the  tendon  of  insertion  of  the  adductor  magnus, 
where  exceptionally  it  may  become  pedunculated  and  is  sometimes  covered  by  a 
bursa.  Exostoses  are  rather  frequently  found  on  the  bones  of  the  face,  par- 
ticularly on  the  nasal  process  of  the  superior  maxilla.  The  so-called  horned 
men  of  the  West  Coast  of  Africa  are  subjects  of  the  latter  deformity. 

The  subungual  exostosis  is  a  small  bony  outgrowth,  averaging  about  the 
size  of  a  cherry  pit,  springing  from  the  ungual  phalanx  of  the  great  toe.  It 
crowds  its  way  through  the  matrix  and  appears  as  a  dull  red  projection 
between  the  nail  and  the  skin.  Ulceration  of  the  overlying  soft  tissues  is  liable 
to  occur.  These  growths  are  the  result  of  inflammatory  processes  having  their 
origin  in  shoe  pressure. 

Treatment. — Osseous  tumors  require  removal  wdienever  they  appear  in 
accessible  situations  and  interfere  with  the  function  of  a  part  or  press  upon 
nerves.  It  is  also  advisable  to  remove  them  when  they  occur  in  favorable 
situations  for  osteosarcomas  or  chondrosarcomas  of  the  extremities,  e.  g.,  the 
tibia,  the  femur,  and  the  humerus. 

Odontomas. — These  tumors  arise  from  tooth-germs.  The  species  in  this 
genus  is  determined  according  to  the  part  of  the  tooth-germ  from  which  it 
springs,  as  follows:  (1)  epithelial  odontomas;  (2)  follicular  odontomas;  (3) 
radicular  odontomas;   (4)  composite  odontomas. 

Epithelial  odontomas  spring  from  persistent  portions  of  the  epithelium 
of  the  enamel  organ,  and  are  usually  found  in  the  inferior  maxilla.  They 
occur  as  small  multilocular  cysts  separated  by  thin  fibrous  septa,  the  cavities  of 
which  contain  a  brownish-colored  mucoid  fluid.  Care  should  be  taken  to 
distinguish  these  growths  from  endotheliomas. 

Odontomas  arising  from  the  tooth  follicle  comprise  the  following:  (1)  Fol- 
licular odontomas  (dentigerous  cysts),  or  those  tumors  which  represent  an  ex- 
panded tooth  follicle.  The  cavity  of  the  C3"st  usually  contains  viscid  fluid  and 
the  crown  or  the  root  of  an  undeveloped  tooth.  (2)  Fibrous  odontomas,  which 
consist  of  a  thickening  of  the  connective-tissue  capsule  or  tooth-sac,  in  which  a 
developing  tooth  is  embedded.  The  thickened  capsule  prevents  the  eruption  of 
the  tooth.  They  are  often  multiple  and  are  usually  attributed  to  rickets.  (3) 
Cementomas.  These  usuallv  result  from  an  ossification  of  the  thickened  tooth- 
sac  constituting  a  fibrous  odontoma,  the  tooth  becoming  embedded  in  a  mass  of 
cementum.  They  occur  very  rarel}^  in  man.  (4)  Compound  follicular  odon- 
tomas. These  result  from  a  want  of  uniformity  in  the. ossification  of  the  cap- 
sule of  a  filDrous  odontoma,  whereby  a  composite  character  is  given  to  the 
tumor.  Small  fragments  of  cementum,  or  dentin,  and  denticles  or  even  per- 
fect teeth  (T  e  1 1  e  n  d  e  r  ,  of  Stockholm)  are  found  in  these  tumors.  They 
are  rare  in  man. 

Radicular  Odontomas. — ^These  spring  from  the  root  after  the  completion 
of  the  crown  of  the  tooth.  The  tumor  usually  consists  of  an  outer  layer  of 
cementum  and  an  inner  layer  of  dentin,  with  a  nucleus  of  calcified  pulp. 


220  TUMORS 

Compound  Odontomas. — These  are  abnormal  growths  of  all  the  elements 
of  a  tooth-germ,  namely,  the  enamel-organ,  papilla,  and  folhcle,  and  therefore 
consist  of  enamel,  dentin,  and  cementum.  The  tumor  usiiall}'  springs  from 
one  or  more  tooth-germs.  They  occur  in  both  the  superior  and  the  inferior 
maxilla,  attaining  the  larger  size  in  the  former.  Occurring  in  the  antrum  of 
Highmore,  they  are  frequently  mistaken  for  exostoses. 

The  diagnosis  of  odontomas  is  of  importance  from  the  fact  that  considerable 
deformity  and  even  excessive  mutilation  may  result  from  their  removal  under 
the  belief  that  malignant  disease  was  present.  This  is  particularly  true  of  the 
fibrous  variety,  which  is  likely  to  be  mistaken  for  myeloid  sarcoma.  The  other 
varieties  have  also  been  mistaken  for  necrosed  bone,  for  unerupted  teeth,  and 
for  exostoses. 

Treatment. — Follicular  odontomas  may  be  successfully  treated  by  the 
excision  of  a  portion  of  the  wall,  the  removal  of  the  contained  tooth  if  one  is 
present,  and  the  thorough  curetting  of  the  cavity.  The  latter  is  obliterated  by 
granulations.  Enucleation  may  sometimes  be  practised  in  this  species  and  is 
usually  necessary  in  the  others. 

Dental  Cysts. — A  fibrous  sac  containing  crystals  of  cholesterm  is  some- 
times found  at  the  root  of  a  dead  permanent  tooth.  These  cysts  var\'  in  size 
from  an  apple  seed  to  an  Enghsh  walnut.  They  spring  from  the  roots  of  the 
teeth  of  both  the  upper  and  the  lower  jaw,  and,  in  the  former  situation,  may 
invade  the  antrum  and  simulate  an  abscess  of  that  cavity.  They  are  usually 
small  and  met  with  only  accidentally  in  the  removal  of  dead  teeth.  They  may, 
however,  give  rise  to  a  suspicion  of  their  presence  by  their  size  or  by  the 
occurrence  of  suppuration. 

The  treatment  of  dental  cysts  consists  in  the  removal  of  the  tooth  roots  and 
the  curetting  of  the  cyst  wall.  In  the  case  of  those  which  invade  the  antrum 
it  will  be  necessary  to  remove  a  small  portion  of  bone  in  order  to  afford  easy 
access  to  the  cyst  cavity.  The  after-treatment  consists  in  frequently  irrigat- 
ing the  cavity  with  an  antiseptic  solution  and  packing  it  with  sterile  gauze 
until  it  is  obliterated  by  the  process  of  granulation. 

Fibromas. — Tumors  composed  of  fibrous  tissue  are  very  rare.  Those 
formerly  described  as  such,  particularly  the  "uterine  fibroid,"  are  now  knowm 
as  myomas  and  fibromyomas.  Tumors  composed  of  closely  applied,  long, 
slender,  fusiform  cells  are  observed  in  the  ovary,  the  uterus,  the  gums,  the 
lar^mx,  on  the  sheaths  of  nerves,  and  in  the  walls  of  the  heart. 

Epulis  is  a  term  loosely  appUed  to  various  tumors  occurring  on  the  gums, 
some  of  w^hich  spring  from  the  tooth  folhcle  (see  Odontomas),  while  others  are 
not  tumors  in  the  true  sense,  but  are  the  result  of  inflammatory  action.  The 
growth  sometimes  called  "malignant  epulis"  is  a  spindle-celled  sarcoma. 
Small  pedunculated  tumors  occurring  on  the  mucous  membrane  of  the  larynx, 
and  ha\dng  a  fibrous  nucleus,  are  rather  frequently  removed  by  laryngologists 
by  meaiLS  of  intralaryngeal  operations. 

Neurofibromas  are  encapsulated  tumors  springing  from  the  sheaths  of 
nerves.  These  growi:hs  vary  in  size  from  a  small  pea  to  a  hen's  egg. 
They  occur  on  almost  any  portion  of  the  cranial  or  spinal  nerves  as  smooth, 
fusiform,  and  mobile  swellings.  They  are  liable  to  undergo  myxomatous 
changes,  with  the  formation  of  cavities  in  the  interior.  This  has  led  to  a  con- 
fusion in  the  use  of  terms  in  designating  these  growths,  such  as  myxoma, 
myxofibroma,  myxosarcoma,  etc.     They  are  easily  enucleated. 


CLASSIFICATION 


221 


SI 


Myxomas. — These  are  tumors  composed  of  soft  jellylike  material  known  as 
myxomatous  tissue.  It  is  identical  with  that  which  surrounds  the  vessels  of 
the  umbilic  cord.  The  best  example  of  this  genus  is  the  common  nasal  polypus. 
Aural  polypi  likewise  consist  of  myxomatous  tissue.  Sutton  describes  a 
myxomatous  tumor  springing  from  the  lumbar  fascia  which  recurred  after 
removal.  He  regarded  it  as  a  sarcoma  which  had  undergone  myxomatous 
degeneration. 

The  few  examples  of  tumor  of  the  heart  which  have  been  observed  have  been 
recorded  as  either  fibromas,  myxomas,  or  fibromyxomas. 

Myelomas. — The  tissue  of  these  tumors  is  identical  with  that  of  the  red 
marrow  of  young  bones.  The  genus  contains  a  single  species,  which  is  found 
only  in  connection  with  the  cancellous  tissue  of  bone.  They  are  very  vascular, 
and  present  on  section  a  deep  red  color.  They  are  characterized  by  the  presence 
of  numerous  large  multinuclear  or  giant  cells,  in  a  bed  of  round  and  spindle  cells. 
They  are  found  wherever  red  marrow  exists,  except  in  the  vertebrae.  They 
are  rarely  found  in  the  patella  or  in  the  acromial  end  of  the  clavicle.  They 
occur  by  preference  in  the  upper  end  of  the  tibia,  the  lower  end  of  the  radius,  the 
body  of  the  lower  jaw  and  the  alveolar 
border  of  the  upper  jaw,  and  the  sternal 
end  of  the  clavicle.  They  are  rarely  seen 
in  patients  above  twenty-five,  and  are  of 
slow  growth.  A  clinical  feature  of  these 
tumors  is  the  parchment-like  crepitation 
present  on  palpation  as  the  bony  cap- 
sule becomes  thinned  by  growth  of  the 
tumor.  With  perforation  of  the  capsule 
pulsation   may  be  present. 

While  the  vascularity  of  these  tumors, 
as  well  as  their  occurrence  in  the  long 
bones  of  young  subjects,  always  excites 
a  suspicion  of  malignancy,  the  absence  of 
both  infection  of  lymphatic  glands  and 
dissemination,  as  well  as  their  non- 
recurrence  if  thoroughly  extirpated  before  perforation  of  the  capsule,  stamps 
them  as  benign. 

Sarcomas. — Sarcomas  may  be  defined  as  tumors  of  connective-tissue 
origin,  the  special  clinical  features  of  which  are  embraced  in  the  term  "  mahg- 
nancy."  Structurally,  almost  any  kind  of  connective  tissue,  such  as  fat,  bone, 
cartilage,  and  sometimes  striated  muscle  tissue,  may  enter  into  their  formation. 
The  special  histologic  feature  of  sarcoma  is  the  fact  that  the  greater  part  of  the 
tumor  consists  of  immature  connective  tissue  with  a  preponderance  of  cells  over 
the  intercellular  tissue. 

In  the  absence  of  all  knowledge  at  the  present  time  as  to  the  cause  of  these 
aberrant  growths  of  connective  tissue,  the  most  convenient  scheme  for  deter- 
mining the  species  is  based  on  the  prevailing  type  of  cell  present,  or  on  the 
presence  of  pigment,  as  in  melanosarcomas.  The  species  having  its  origin  in 
pigmented  moles  is  called  alveolar  sarcoma.  Each  species  may  be  subdivided 
into  one  or  more  varieties,  with  such  qualifying  names  as  lymphosarcomas, 
myosarcomas,  chondrosarcomas,  etc. 


iMf!M 


Fig.  37. — Round-celled  Sarcoma. 


222 


TUMORS 


Round-celled  Sarcomas. — This  species  is  the  most  generalized  tumor  found 
in  man.  It  may  attack  any  portion  of  the  body  and  occur  in  any  tissue.  It  is 
found  at  all  periods  of  life,  even  in  the  fetus  in  utero.  It  is  very  simple  in  con- 
struction, consisting  almost  exclusively  of  round  cells,  each  of  which  contains  a 
large,  round,  vesicular  nucleus  and  a  small  proportion  of  protoplasm.  The 
intercellular  substance  is  very  scanty,  but  is  plentifully  supplied  with  blood- 
vessels, which  often  appear  as  mere  channels  between  the  cells  (Fig.  37).  In 
the  variety  known  as  large  round-celled  sarcoma  the  cells  are  of  unequal  size, 
some  of  them  being  multinuclear  and  resembling  myeloid  cells. 

Lymphosarcomas. — This  rare  and  excessively  malignant  species  derives  its 
name  from  the  resemblance  of  its  tissue  to  that  of  the  lymph-glands.  It  occurs 
particularly  in  the  mediastinum,  in  the  connective  tissue  beneath  the  pleura 
and  peritoneum,  in  the  tonsils  and  at  the  base  of  the  tongue,  and  in  the  testes. 
The  cells  are  identical  with  those  of  the  round-celled  species  but  are  contained 
in  dehcate  meshes  (Fig.  38). 

Spindle-celled  Sarcomas. — This  species  derives  its  name  from  the  fusiform 

character  of  its  cells.  Hyaline  cartilage 
is  frequently  found  in  this  species,  from 
which  circumstance  it  is  known  as 
chondrosarcoma.  In  other  examples 
the  sarcomatous  tissue  apparently  con- 
sists of  slender  cells  with  almost  an  entire 
absence  of  protoplasm.  In  others, 
again,  the  cells  are  large,  distinctly  fusi- 
form, and  rich  in  protoplasm.  They 
resemble  the  cells  of  young  unstriped 
muscle-fiber ;  occasionally  transverse 
striae  are  present,  as  in  young  striated 
muscle-fiber.  This  variety  is  known 
as  myosarcoma  or  rhabdomyosar- 
coma. 

In  chondrosarcomas  the  presence  of 
immature  hyaline  cartilage  may  be  so 
pronounced  as  to  confuse  the  diagnosis.  This  is  particularly  true  when  the 
cartilage  is  calcified  or  ossified;  under  these  circumstances  the  tumor  may  be 
erroneously  described  as  a  simple  chondroma.  On  removal,  however,  it 
recurs,  and  the  recurrent  tumor  may  show  no  evidence  of  cartilage  but  may 
conform  to  the  structure  of  a  pure  spindle-celled  or  a  round-celled  sarcoma. 

Myosarcomas. — Strange  as  it  may  seem,  these  rarely  make  their  appearance 
in  connection  with  voluntary  muscles,  but  occiu"  by  preference  in  the  kidney, 
cervix  uteri,  testis,  and  parotid  glands,  situations  in  which,  under  normal  con- 
ditions, no  muscle-cells  of  the  striped  variety  are  found.  They  have  also  been 
found  at  the  angle  of  the  jaw,  in  connection  with  the  periosteum  of  the  orbit, 
on  the  scapula  and  the  tuberosity  of  the  ischium. 

Spindle-celled  sarcomas  occurring  in  the  subperiosteal  connective  tissue  of 
the  abdomen  and  pelvis  present  some  peculiar  features,  these  consisting  of  an 
almost  uniformly  globular  shape,  large  size,  slow  growth,  and  lesser  malig- 
nancy as  compared  with  the  other  sarcomas.  These  retroperitoneal  sarcomas 
sometimes  attain  a  large  size;  in  a  case  operated  on  by  the  author  the  tumor 


Fig.  38. — Lymphosarcoma. 


CLASSIFICATION  223 

weighed  iii')war(l  of  30  pounds.  The}'  have  Ijeen  most  freqiientty  observed  in 
the  perirenal  tissues  and  between  the  layers  of  the  broad  ligament. 

The  cells  of  spindle-celled  sarcomas  (Fig.  39)  vary  greatly  in  size  and  are 
prone  to  collect  in  bundles  which  form  in  different  directions,  so  that  when 
sections  are  made  of  the  tumor  mass  the  spindle  shape  of  the  cells  is  not 
uniformly  preserved  in  the  microscopic  appearances,  a  circumstance  which 
may  easily  lead  to  error  in  the  histologic  differentiation.  When  the  so-called 
giant-cells  are  present,  these  are  multinuclear  (Fig.  40). 

Melanosarcomas. — This  term  is  applied  to  sarcomas  in  which  pigment 
occiu's.  The  greater  majority  of  tumors  containing  pigment  are  sarcomatous 
in  character.  The  amount  of  pigment  present  varies  greatly.  The  pigment 
granules  are  found  not  only  in  and  among  the  characteristic  cells  of  the  tumor 
and  in  those  of  the  fibrous  matrix,  but  also  in  the  walls  of  the  vessel. 

This  species  of  sarcoma,  as  it  occurs  usually  in  the  skin,  has  its  origin  in 
connection  with  pigmented  moles.  It  is  next  most  frequently  found  in  con- 
nection with  the  matrix  of  the  nail,  or  in  the  neighborhood  of  it,  or  even  in  the 
nail  itself.     It  also  has  its  origin  in  the  ^^-^^"^^^^^^^^ 

pigmented    skm  about   the   genitals   and  y^^Z^^^'^-^^^^j, 

anus.  ^^/'/r,~_  - 'r^^^-f-f^^'^, 

Wliile  pigmented  moles  may  remain  //f^^/' ^'-^^x  '''C  -7.''',;  ')l'^^ 
quiescent  for  years,  it  occasionally  hap-  .'i  ''i-,^-"^'  ■--"i---  -,:?r^^;  ^i^^yH  ^^ 
pens  that,  as  life  advances,  ulceration 
accompanied  by  bleeding  takes  i^lace. 
Neighboring  lymph-glands  become  the 
seat  of  secondary  pigmented  sarcoma- 
tous deposits,  and  the  skin  over  these, 
becoming  infected,  breaks  down,  so  that 
the  fungous  mass  beneath  is  exposed. 
The  latter  gives  rise  to  frequent  hemor- 
rhage, which  is    fatal  when   it  occurs  in  

the  neighborhood  of   large  vessels.     Dis-         fig.  39.-Spindle-celled  Saecoma. 
semination,  which  does  not  always  take 

place,  results  in  secondary  deposits  in  the  liver,  lungs,  kidney's,  or  brain. 
Lymphatic  glandular  infection,  dissemination,  and  fatal  secondary  deposits  in 
distant  organs  may  occur  from  simple  increase  in  size  of  the  mole,  without 
ulceration.  Finally,  in  rare  instances  large  quantities  of  pigment  may  be 
produced,  apparently  by  the  tumor,  and  fed  into  the  circulation,  to  be 
eliminated  by  the  kidnej^s  as  melanin,  no  secondary  deposits  of  sarcoma 
taking  place. 

Xodules  of  melanosarcoma  arising  in  connection  with  the  nails  usually 
ulcerate  quickly,  and  rapid  dissemination  and  secondary  deposits  are  the  rule. 
The  pigment  in  the  primary  nodules  is  sometimes  very  scanty;  the  secondary 
deposits,  however,  may  contain  a  large  amount. 

Melanotic  tumors  maj^  be  either  sarcomatous  or  carcinomatous  in  character; 
in  either  case  the  characteristic  feature  consists  of  the  more  or  less  pronounced 
pigmentation  of  the  growth.  Inasmuch  as  the  pigment  particles  have  their 
origin  in  the  normal  sources  of  pigment,  melanomas  are  found  most 
frequently  in  the  uveal  tract  of  the  globe  of  the  eye  and  least  frequenth"  on 
mucous  membrane.     Their  occurrence  in  the  skin  depends  on  the  presence 


^;  :~-5i>^>: 


224  TUMORS 

of  pigment  in  the  rete  miicosum,  to  which  situation  the  pigment  grainiles  are 
ahiiost  entirely  confined  in  the  white  race.  The  comparatively  greater  fre- 
quenc}^  with  which  these  growths  occur  in  the  neighborhood  of  the  anus  and 
external  genitals,  particularly  in  the  labia  majora,  is  accounted  for  by  the 
greater  amount  of  pigment  in  these  situations.  The  pathologic  connection 
between  the  presence  of  pigment  matter  and  the  occurrence  of  melanomas  has 
not  as  yet  been  satisfactorily  explained. 

The  General  Character  of  Sarcomas. — Sarcomas  differ  from  all  other 
connective-tissue  tumors  in  the  absence,  as  a  rule,  of  a  proper  capsule,  and  the 
consequent  ease  with  which  infiltration  of  the  immediately  adjacent  tissues 
and  remote  dissemination  occur. 

The  vessels  supplying  sarcomas  may  be  very  large  and  numerous,  though 
the  circulation  itself  is  mainly  capillary.  When  the  growth  occurs  in  localities 
where  the  blood-supply  is  abundant  and  the  arterial  anastomosis  free,  as,  for 
instance,  in  the  neighborhood  of  the  knee-joint,  the  blood-supply  to  the  tumor 
from  the  vessels  of  the  part  is  correspondingly  increased  and  the  hemor- 
_,,^-^„  rhage  is  alarming  in  case  of  injury,  ulcer- 

^ffl^lr^^^^^  ation,  or  when  attempts  are  made  to  dis- 

sect out  the  tumor. 

In  the  round-celled  species,  as  well  as 
in  all  soft  and  rapidly  growing  varieties, 
the  circulation  is  specially  free,  as  shown 
by  the  pulsation  which  is  frequently  pres- 
ent. Owing  to  the  extreme  tenuity  of  the 
vessel  walls  hemorrhage  frecjuently  occurs 


^^^:^t^t-c>.-*     ^f^  V j^^^****;^,^;^-  withm    the    mass,    after    slight    m  uries. 

^ ^.£&<   3^'S*^'^>*''         ^.j*-"'  asations    ot     blood    may    take    place  m 

^t%^'^'^~\J!^^^^'  situations  in  which  the  previous  presence 

p.^v_ .  -    -     *''■'•'  of  a  large  growth  may  be  easily  overlooked. 


^^-iT^^''^'^-^^  jifet  Np-'5£^V^'»-^'''       Under  these  circumstances  large  extra v- 


Fig.  40.-GIANT-CELLED  Sarcoma.  ^s,  for  instance,  in  the  gluteal  region,  and 

the  collection  maybe  incised  as  an  abscess. 

The  ever  present  and  inevitable  tendency  of  sarcomas  to  destroy  life,  as 
expressed  in  the  term  "malignancy,"  is  displayed  through  (1)  their  ubiquitous 
distribution;  (2)  their  infiltrating  properties;  (3)  their  tendency  to  penetrate 
between  surrounding  structures;  (4)  their  dissemination. 

Distribution. — While  sarcomas  may  occur  in  any  portion  of  the  body, 
owing  to  the  widespread  distribution  of  connective  tissue,  they  are  observed 
springing  with  greater  frequency  from  subcutaneous  tissue  and  fascia,  peri- 
toneum, the  testis  and  ovary.  They  are  very  infrequently  found  in  connection 
with  the  spleen,  bowel,  or  uterus,  and  occur  as  primary  growths  with  great 
rarity  in  the  organs  which  are  usually  first  affected  by  secondary  deposits, 
namely,  the  lungs  and  liver. 

Sarcomas  of  mucous  membranes  are  rare  as  compared  with  carcinomas 
of  these  structures.  They  were  formerly  supposed  to  occur  in  the  endome- 
trium of  the  uterus  after  full-term  delivery  or  abortion  (see  Choriomas). 
Sarcoma  of  the  vagina  occurs  in  young  children  and  in  the  middle-aged.  Rare 
and  exceptional  instances  of  sarcomas  springing  from  the  mucous  membrane 
of  the  alimentary  canal  have  been  observed. 


CLASSIFICATION  225 

'I'lio  infiltrating  properties  of  .sarcomas  are  ol)sorvcd  in  a  marked  manner 
in  localities  whei-e  i-aj)i(lly  growing  lympiioKarcomas  occur  adjacent  to  extensive 
jilanes  of  connective  tissue,  as,  for  instance,  in  the  superior  mediastinum,  where 
the  growth  en\'elops  trachea  and  bronchi  and  extends  to  the  roots  of  the  lungs, 
follows  the  aorta  and  other  large  vessels  to  invest  the  pericardium,  and  even  in 
some  instances  invades  the  heart.  Projections  of  the  tumor  also  pass  in  an 
upward  direction  along  the  sheaths  of  the  large  vessels  to  the  head  and  appear  in 
the  posterior  triangles  of  the  neck.  In  this  extensive  infiltration  the  veins  are 
first  com})ressed,  owing  to  the  thinness  of  their  walls,  and  interference  with  the 
venous  circulation  ensues.  In  some  instances  the  walls  of  the  veins  are 
infiltrated  with  the  sarcomatous  tissue.  The  larger  arterial  trunks,  though 
completely  surrounded  by  the  growth,  are  not,  as  a  rule,  appreciably  com- 
pressed, nor  do  they  become  infiltrated.  The  trachea  and  bronchi  suffer  from 
compression,  their  nutrition  is  interfered  with,  and  erosion  follows.  The 
nutrition  of  the  lung  tissue  suffers  from  interference  with  the  blood-supply  and 
pnevunonia  and  gangrene  result.  Difficulty  of  swallowing  is  not  an  invariable 
or  marked  feature  in  these  cases,  however,  and  neighboring  lymph-glands  may 
be  completely  invested  by  the  growth  without  showing  signs  of  infection. 

The  tendency  of  sarcoma  to  penetrate  between  surrounding  structures 
differs  from  its  infiltrating  properties  as  follows:  while  in  the  former  the  extension 
takes  place  by  growth  from  the  periphery  and  the  invasion  is  an  actual  vital 
process,  in  the  feature  under  consideration  the  tumor  follows  the  lines  of  least 
resistance  in  its  penetrating  or  burrowing  tendency,  the  process  being  a  purely 
mechanic  one.  In  this  manner  the  cavity  of  the  cranium  may  be  invaded  by 
a  sarcoma  originally  springing  from  the  upper  jaw,  which,  after  filling  the 
sphenomaxillary  fossa,  forces  its  way  alongside  the  second  division  of  the  fifth 
nerve  through  the  foramen  rotundum. 

Joint  cavities  are  exceptionally  invaded  by  either  of  the  processes  of 
extension  described.  The  synovial  membrane  seems  to  serve  as  a  barrier  in 
the  case  of  the  penetrating  tendency  of  the  growth,  and  the  absence  of  venous 
channels  in  the  articular  cartilages  removes  the  most  favorable  condition  for 
infiltration.  When  joint  cavities  are  invaded,  it  is  through  infection  and 
implication  of  the  synovial  structures. 

Dissemination  or  metastasis  is  that  property  possessed  by  sarcomas  of 
reproducing  themselves  in  distant  organs.  This  process  takes  place  principally 
through  the  veins,  the  sarcomas  being  devoid  of  lymphatics.  It  consists  in  the 
grow^th  of  minute  portions  of  the  tumor  into  the  vessels,  w^hich  become 
detached  and  are  carried  by  the  blood-current  to  remote  organs.  Here  they  are 
arrested  by  the  capillaries,  become  engrafted,  and  grow  as  secondary  tumors. 
Any  organ  of  the  body  may  become  affected  by  sarcoma  in  this  manner,  and 
that,  too,  from  a  primary  growth,  w^hatever  its  location.  If  the  primary  tumor 
■is  situated  in  the  area  of  the  portal  circulation,  however,  the  liver  will  be  the 
organ  most  likely  to  be  secondarily  affected;  otherwise  the  lung  is  the  organ 
in  which  secondary  sarcomas  are  most  commonly  found. 

Finally,  the  secondary  or  degenerative  changes  to  which  sarcomas  are 
subject  are  to  be  mentioned.  These  consist  of  (1)  the  formation  of  spurious 
C3'sts  from  hemorrhage  within  the  growth,  as  already  alluded  to ;  (2)  liquefaction 
of  the  tissues  of  the  tumor  and  myxomatous  changes,  the  latter  being  rather 
common;  (3)  calcification  in  sarcomas  of  slow  growth,  particularly  in  those 
16 


226  TUMORS 

connected  with  bone  ;  (4)  necrosis  of  the  tumor.  This  is  more  frequently 
observed  in  the  interior  of  very  large  tumors  and  results  in  the  formation  of  a 
spurious  cyst  containing  fluid  and  detached  and  necrotic  portions  of  the  growth. 

Angiosarcoma,  a  rare  and  remarkable  growth  depending  on  a  cellulai- 
overgrowth  in  the  sheath  of  the  smaller  vessels,  and  on  microscopic  examination 
resembling  superficially  the  lobules  of  the  liver,  has  been  described  by  Z  i  e  g  1  e  r . 

Treatment  of  Sarcomas. — The  successful  treatment  of  sarcomas  deinands 
early  and  extensive  extirpation.  Only  considerations  of  safety  should  limit 
the  extent  of  the  latter.  No  operation  should  be  undertaken  unless  it  can  be 
made  to  include  every  vestige  of  suspected  tissue.  When  a  limb  is  affected, 
amputation  above  the  next  joint  should  be  the  invariable  rule.  Even  this  may 
not  be  sufficient,  as  in  the  case  of  the  upper  third  of  the  thigh.  In  the  case  of  the 
arm,  sarcomas  of  the  humeral  region,  whether  of  the  bone  or  soft  parts,  demand 
amputation  of  the  entire  upper  extremity  (W.  W.  Keen,  R.S.  Fowler). 
(See  Interscapulothoracic  Amputation  (vol.  ii).  Sarcomas  of  the  subcutane- 
ous connective  tissue  or  fascial  structures,  when  situated  on  a  limb,  are  best 
submitted  to  amputation.  When  situated  elsewhere,  they  should  be  removed 
as  frequently  as  they  recur.  Inoperable  cases  may  be  submitted  to 
injections  of  the  toxins  of  Streptococcus  erysipelatis  and  Bacillus  pro- 
digiosus  (C  o  1  e  y).  Treatment  by  this  method  offers  a  slight  hope,  of  which 
the  patient  should  be  given  the  benefit.  Recurrences  in  regions  inaccessible 
to  further  operation,  particularly  if  the  tumor  is  of  the  giant-celled  variety, 
should  also  be  treated  by  the  toxins. 

Neuromas. — ^A  neuroma  is  a  tumor  springing  from  the  sheath  of  a  nerve, 
the  structure  of  the  neuroma  resembling  the  structure  of  the  sheath.  They 
are  usually  observed  as  neurofibromas  and  include  the  so-called  subcutaneous 
painful  tubercle.  This  is  a  small,  shotlike,  and  excessively  painful  and  sensi- 
tive body  felt  beneath  the  skin.  It  occurs  most  frec|uently  in  men.  Excision 
is  always  followed  by  cure. 

The  term  neurofibromatosis  is  now  applied  to  the  following:  (1)  multiple 
neuromas;  (2)  molluscum  fibrosum;  (3)  plexiform  neuromas;  (4)  ghomas  of  the 
brain  and  spinal  cord. 

Multiple  neuromas  are  of  but  slight  surgical  importance,  except  in  those 
cases  in  which  the  growths  are  sufficiently  few  in  number  to  admit  of  excision. 
The  same  may  be  said  of  molluscum  fibrosum,  which  sometimes  appears  in  a 
mild  form  as  a  single  pedunculated  groAvth,  particularly  in  the  labium  majus. 
Exceptionally  it  may  spring  from  the  tissues  in  and  about  the  nipple.  AVhen 
these  occur  in  large  numbers  as  sessile  growths,  they  are  not  amenable  to 
operative  interference. 

A  form  of  fibromatosis  confined  to  a  particular  nerve  or  plexus  is  called 
plexiform  neuroma.  This  may  affect  any  portion  of  either  the  cranial  or  the 
spinal  nerves.  There  is  a  general  enlargement  and  elongation  of  the  nerves 
distributed  to  a  part.  The  skin  becomes  raised  and  thinned  over  the  area  and 
is  often  a  bluish  color.  The  mass  presents  a  rather  uniform  appearance 
(Fig.  41,  4)  with  a  baglike  feel.  Mobile  and  nonsensitive  bodies  feeling  like 
worms  when  manipulated  and  varying  in  size  are  present  in  the  interior.  The 
connective  tissue  of  the  nerve  sheath  is  greatly  increased  and  converted  into  a 
gelatinous  material,  like  that  of  the  umbilic  cord.  The  presence  or  absence  of 
changes  in  the  axis-cylinder  is  as  yet  undetermined. 


CLASSIFICATION 


227 


Gliomas  of  the  brain  and  spinal  cord  are  of  but  slight  surgical  interest, 
owing  to  the  fact  that  their  relation  to  the  important  structures  hi  which  they 
occur  usually  renders  successful  operative  interference  out  of  the  question. 

Angiomas. — The  characteristic  feature  of  this  genus  of  the  connective- 
tissue  tyi)e  of  tumors  is  the  abnormal  formation  of  blood-vessels.  Three  species 
are  included,  as  follows:  (1)  simple  nevus;  (2)  cavernous  nevus;  (3)  plexiform 
angioma. 

Simple  Nevus. — This  may  occur  as  a  simple  discoloration  of  the  skin,  in 
var3'ing  extent,  and  may  affect  any  part  of  the  body. 
These  discolorations  are  commonly  known  as  "  port 
wine  stains."  The  form  known  as  telangiectasis 
consists  of  an  abnormal  collection  of  arterioles  in 
the  skin  and  subcutaneous  connective  tissue.  It 
may  be  present  at  birth  as  a  small  red  spot  which  may 
be  easily  overlooked.  During  the  first  few  weeks  of 
life  the  spot  enlarges  rapidly  and  a  pulsating  tumor 
of  the  subcutaneous  connective  tissue  arises.  A 
specially  dangerous  location  for  these  growths  is 
over  the  parotid  gland,  the  vessels  of  which  they  may 
involve,  so  that  extirpation  of  the  gland  may  be  ren- 
dered necessary.  This,  in  infants,  is  a  specially 
difficult  and  dangerous  operation  and  is  almost 
certain  to  be  followed  by  facial  paralysis  of  the  corre- 
sponding side,  owing  to  unavoidable  injury  of  the 
branches  of  the  seventh  nerve. 

In  the  case  of  a  young  woman  under  my  care  an 
apparently  innocent  telangiectasis  of  the  tragus  and 
external  ear  assumed  a  most  vicious  and  threaten- 
ing aspect  during  the  third  month  of  pregnancy.  The 
skin  finally  gave  way  and  a  most  profuse  hemorrhage 
took  place,  necessitating  simultaneous  ligation  of  the 
temporal,  facial,  and  external  carotid  arteries,  the  lat- 
ter bej'ond  the  occipital  branch.  In  a  subsequent 
pregnancy  the  phenomena  returned,  and  it  became 
necessary  to  remove  the  entire  ear  and  ligate  each 
vessel  of  supply  separatel3^  A  cure  w^as  thus  ef- 
fected. 

This  form  of  nevus  has,  with  some  appearance 
of  probability,  been  ascribed  to  a  hereditary  pre- 
disposition. 

Cavernous  nevus,  or  erectile  tumor,  occurs 
most  frequently  in  the  skin,  where  it  forms  a  red  or  blue  tumor  elevated  above 
the  surface.  Pulsation  may  be  present.  The  cavernous  structure  consists  of 
variously  shaped  spaces  and  sinuses  together  with  some  vessels.  The  tumor 
may  be  emptied  of  its  contained  blood,  but  if  emptied  it  slowly  refills.  Caver- 
nous nevi,  as  a  rule,  are  congenital.  They  may  enlarge  rapidly  and  attain  a 
large  size,  particularly  in  the  breast  of  either  male  or  female,  and  may  even 
threaten  life.  They  occasionally  occur  in  the  tongue,  where  they  cause  but 
slight  inconvenience,  as  a  rule,  except  for  the  accidental  injury  and  the  con- 


mJ^m^ 

— 1 

k"^^L%^ 

e — 3 

n^^^KBip 

V 

m 

1 

fi 

1 

— 5 

iJ 

Fig.  41. — Plexiform  Neu- 
romas OF  Arm  (after 
Sutton). 

1,  Humerus;  2,  mus- 
culospiral  nerve ;  3,  supina- 
tor longus  muscle ;  4,  neu- 
roma; 5,  neuromas  on  the 
cutaneous  branches  of  the 
musculospiral  nerve. 


228 


TUMORS 


sequent  alarming  hemorrhage  to  which  they  give  rise  and  which  may  finally 
necessitate  excision  of  the  corresponding  half  of  the  tongue. 

Cavernous  nevi  have  been  observed  in  the  voluntary  muscles,  in  the 
larynx,  and,  in  a  case  of  the  author's,  in  the  broad  ligament.  Small 
cavernous  nevi  have  also  been  found  in  the  liver. 

Plexiform  angiomas  are  comparatively  rare.  They  comprise  the  tumors 
formerly  called  "aneurism  by  anastomosis"  and  "cirsoid  aneurism."  In 
structure  they  consist  of  moderately  enlarged  vessels  arranged  parallel  to  one 
another.  Either  arteries  or  veins  may  predominate  in  their  formation,  or  the 
tumor  may  consist  of  both  in  about  equal  proportions. 

A  practical  point  in  regard  to  telangiectatic,  cavernous,  and  plexiform 

angiomas  is  the  necessity  for  their  destruc- 
tion or  excision  on  the  first  appearance 
of  signs  of  activity  and  growth,  in  order 
to  prevent  them  from  assuming  threaten- 
ing or  excessively  dangerous  proportions. 
Lymphangiomas. — There  are  three 
species  comprised  in  this  genus,  namely, 
(1)  lymphatic  nevus;  (2)  cavernous  lym- 
phangioma; (3)  lymphatic  cyst.  Lym- 
phangiomas consist  essentially  of  the 
structural  formation  of  Ij^mphatics  and 
bear  the  same  relation  to  lymph-vessels 
as  angiomas  bear  to  blood-vessels. 

Pure  lymphatic  nevi  are,  as  a  rule,  col- 
orless.    They  may,  however,  contain  some 
blood-capillaries,  in   which  case  they  ap- 
pear as  pale  pinkish  patches  slightly  raised 
above  the  level  of  the  skin.     Occasionally 
they  are  multiple.     Lingual  lymphangi- 
omas occur  as  localized  clusters  of  pap- 
illae consisting  of    dilated  lymphatic  ves- 
sels projecting  from  the  mucous  membrane 
of  the  tongue  (macroglossia,  Fig.  42). 
Cavernous  lymphangiomas,  as  the  name  implies,  are  identical  in  struc- 
ture with  cavernous  nevi,  their  cavities,  however,  being   filled  with   lymph 
instead  of  blood.      Macroscopically  they  are  not  to  be  distinguished  from 
lymphatic  nevi. 

Lymphatic  cysts  are  easily  recognized  congenital  cysts  occurring  either 
as  unilateral  or  as  bilateral  growths.  They  affect  by  preference  the  anterior 
triangle  of  the  neck,  though  they  may  be  found  in  the  middle  line  or  may  extend 
into  the  posterior  triangle.  In  some  instances  they  extend  into  the  axiha 
and  superior  mediastinum.  The  cyst  may  be  unilocular  or  multilocular,  with 
or  without  intercommunication  of  the  loculi.  They  originate  beneath  the  deep 
fascia,  but  portions  of  the  tumor  may  become  subcutaneous.  If  the  overlying 
skin  becomes  stretched  and  thinned  by  pressure  from  within — a  not  uncommon 
occurrence — the  tumor  may  exhibit  marked  translucency.  Their  resemblance 
to  hydrocele  of  the  tunica  vaginalis  in  this  respect  has  led  to  the  appellation 
"hydrocele  of  the  neck." 

These  congenital  cervical  cysts  have  a  special  tendency  to  spontaneous 


Fig.  42. — Macroglossia. 


CLASSIFICATION  229 

cffacpiiient,  through  cither  atro])lii('  oi'  inflammator}'-  changes.  In  the  latter 
case  their  disappearance  is  preceded  by  sudden  increase  in  size,  with  the  develop- 
ment of  heat  and  tenderness.  In  the  rare  instances  in  which  they  ha\'e  per- 
sisted until  puberty  and  attempts  have  been  made  to  emj)ty  the  cyst, 
symptoms  of  collaj^se  have  followed  (B  i  r  k  e  1 1). 

Endotheliomas. — 'Jliis  is  a  rare  species  of  tumor,  usually  containing  dilated 
lympliatics,  and  arising  from  the  endothelium  of  lymiah-vessels,  and  blood- 
vessels. They  may  infrequently  attain  a  large  size,  are  liable  to  degenerative 
changes,  and  exhibit  a  tendency  to  recurrence  after  removal.  They  arise  in 
connection  with  the  gums,  in  the  mammary  glands,  in  the  skin  in  association 
with  moles  and  warts,  in  the  pleura,  and  in  the  cerebral  and  spinal  dura. 

Myomas. — Tumors  composed  of  unstriped  muscle-fiber  are  called 
myomas.  They  are  of  very  rare  occurrence,  with  the  exception  of  uterine 
myomas,  and  are  exclusively  confined  to  localities  in  which  iuA-oluntary  muscle- 
fiber  normally  exists,  such  as  the  upj^er  portion  of  the  alimentary  tract  (the 
esophagus,  stomach,  and  duodenum),  the  bladder,  and  the  uterus.  The 
similarity  existing  between  unstriped  muscle-fiber  and  the  fusiform  cells  of 
sarcoma  renders  the  differentiation  difficult,  and  these  difficulties  are  still 
further  enhanced  by  the  transverse  striations  sometimes  observed  in  the  spindle- 
cells  of  malignant  tumors,  and  which  are  likewise  obsers^ed  in  voluntary 
muscle  in  the  embryonic  stage.  Tumors  consisting  of  mature  striated  or 
voluntary  muscle-fiber  have  not  been  observed. 

EPITHELIAL  TUMORS 

In  the  study  of  epithelial  tumors  it  is  important  to  bear  in  mind  that  epithe- 
lium, the  presence  of  which  is  the  essential  and  distinguishing  characteristic  of 
this  group,  is  widespread  in  its  distribution  and  disposed  in  such  a  manner  as  to 
serve  many  and  important  functions.  Wherever  epithelium  exists,  whether 
as  a  protective  covering,  as  in  the  case  of  the  epidermis,  or  as  the  cellular  lining 
of  simple  or  complex  glands  or  of  their  ducts,  these  epithelial  tumors  may  arise. 

The  three  genera  of  this  group  of  tumors  are  (1)  papillomas;  (2)  adenomas; 
(3)  carcinomas. 

Papillomas. — The  inost  familiar  example  of  a  papilloma  is  the  common 
wart.  Warts  consisting  of  overgrown  papillae  ma}^  occur  in  crops  on  the 
hands  of  children  or  about  the  anus  and  glans  penis  of  patients  with  gonorrhea. 
A  skin  wart  which  persists  and  increases  in  size,  particularly  when  it  contains 
pigment  granules,  may  ultimately  become  the  point  of  origin  of  a  melanosar- 
coma.  Solitary  soft  red  warts  of  rapid  growth  simulate  malignant  tumors. 
The  surface  cells  of  skin  warts  are  sometimes  converted  into  cutaneous  horns. 
The  mucous  membrane  of  the  cheeks,  nose,  and  larynx  may  be  the  seat  of 
warty  growths  similar  in  structure  to  those  which  occur  on  the  skin.  In  the 
larjmx  they  may  produce  suffocation. 

Villous  Papillomas. — The  favorite  seat  of  these  growths  is  the  mucous 
membrane  of  the  liladder.  They  are  occasionally  observed  in  the  renal  peh'is. 
They  may  be  either  pedunculated  or  sessile.  Structurally  they  consist  of  a 
dehcate  and  very  vascular  connective-tissue  bod}'  covered  with  epithelium. 
They  are  usually  single,  but  they  may  be  multiple.  They  ma_v  obstruct  the  ureter 
or  urethra  and  not  infrecjuently  give  rise  to  severe  hemorrhage.  Those  occur- 
ring in  the  renal  pelvis  may  exceptionally  be  associated  with  villous  growths 


230 


TUMORS 


in  the  bladder.  Ilceration  of  renal  and  vesical  papillomas  causes  a  close 
simulation  of  malignant  disease  in  these  regions. 

Intracystic  villous  papillomas  are  observed  springing  from  the  lining  of 
cysts  of  the  mamma  (Fig.  43).  These  have  the  same  structural  characteristics 
as  vesical  papillomas.  On  section  the  cavity  of  the  cyst  contains  a  brownish 
colored  fluid,  the  result  of  hemorrhage  from  the  villous  growth.  When  the  cyst 
is  formed  of  a  galactophorous  duct,  this  same  brownish  fluid  may  he  discharged 
at  times  from  the  nipple. 

Psammomas  are  confined  exclusively  to  the  pia  mater  of  the  brain  and 
spinal  cord  and  are  of  slight  surgical  interest. 

Cutaneous  Horns. — These  ma}-  form  in  situations  where  sebaceous  glands 
exist  (sebaceous  horns);  as  wart  horns  on  the  penis  or  pinna;  as  cicatrix 
horns  springing  from  a  scar  left  by  a  burn;  or  as  nail  horns  on  the  toes  of 
bedridden  patients  and  elderly  unclean  individuals. 


Fig.  43. — Intracystic  Papillomas  of  Breast. 


Adenomas. — A  tumor  arising  from  the  epithelial  elements  of  a  secreting 
gland  is  called  an  adenoma.  The  principle  of  its  construction  is  typic  of 
secreting  gland  tissue,  namely,  narrow  channels  lined  with  epithelium,  with  a 
connective-tissue  basis  containing  blood-vessels.  In  some  examples  the  epithe- 
lial element  greatly  predominates,  while  in  others  the  disproi)ortionate  amount 
of  connective  tissue  present  is  suggestive  of  sarcoma  (adenosarcoma). 

Adenomas  occur  as  encapsulated  growths  in  the  mamma  and  liver,  and  in 
large  secreting  glands,  such  as  the  parotid  and  thyroid.  In  the  glandular 
structure  of  the  mucous  membranes  they  occur  as  pedunculated  growths. 
They  occur  singly  or  as  multiple  growths  springing  from  the  same  gland.  They 
vary  greatly  in  size.  They  may  be  found  in  a  child's  rectum  as  jDedunculated 
growths  as  small  as  a  pea ;  in  the  breast  of  a  woman  thej'  will  occasionally  grow 


CLASSIFICATION  231 

to  the  sizo  of  a  large  cocoaniit.    When  multiple,  they  are  likely  to  be  small,  while 
solitary  growths  arc  frequently  large. 

These  growths  do  not  affect  lymphatic  glands  nor  cause  secondary  deposits, 
and  when  thoroughly  extirpated  they  do  not  recur.  The  dangers  of  their 
presence  arise  principall>'  from  mechanic  disturbances.  The  frequency  with 
which  these  tumors  coexist  with  carcinomas  in  the  same  gland  has  given  rise  to 
the  erroneous  belief  that  they  may  be  transformed  into  cancers. 

A  cystic  adenoma  is  present  when  the  epithelium-lined  spaces  of  the  growth 
are  filled  with  fluid.  The  latter,  however,  is  identical  with  the  normal  secretion 
of  the  gland  from  which  the  growth  springs.  This  variety  is  found  most  fre- 
quently in  the  mamma,  where  it  is  sometimes  in  communication  with  a  galacto- 
phorous  duct.  Under  these  cirumstances  the  fluid  can  be  expressed  from  the 
nipple  and  constitutes  a  valuable  diagnostic  sign. 

Fibroadenomas  affect  particularly  the  breast.  They  occur  as  almond- 
shaped  growths  affecting  the  upper,  outer,  and  lower  quadrants  specially. 
Their  size  varies,  but  it  is  not  rare  to  find  them  larger  than  an  English 
walnut.  They  are  most  commonly  found  after  the  age  of  puberty.  They  are 
usually  situated  in  the  superficial  portion  of  the  gland,  though  they  may  be 
deeply  placed.  They  are  not  infrequently  multiple  and  it  is  not  unusual  to 
find  both  breasts  the  seat  of  these  growths. 

Complex  adenomas  have  been  observed  in  the  mamma,  combining  the 
fibrous  structure  of  the  fibroadenomas  and  numerous  and  large  cysts.  The 
latter  are  sometimes  the  seat  of  intracystic  growths.  The  cyst,  under  these 
circumstances,  corresponds  to  a  dilated  galactophorous  duct.  These  tumors 
are  distinctly  isolated  from  the  remainder  of  the  gland  by  a  capsule  and  may 
attain  a  large  size. 

Sebaceous  adenomas  are  growths  springing  from  the  sebaceous  glands  and 
presenting  the  usual  clinical  signs  of  wens.  On  section,  however,  they  are 
found  to  be  composed  of  lobules  which  represent  an  overgrowth  of  a  sebaceous 
gland.  These  growths  ulcerate  frequently,  the  ulceration  being  accompanied 
by  a  fetid  discharge;  they  then  constitute  one  of  the  varieties  of  "fungous 
wen." 

Sebaceous  cysts  or  wens  are  collections  of  sebum  in  sebaceous  glands. 
They  are  generally  believed  to  arise  from  obstruction  of  the  orifice  of  the  follicle 
and  distention  of  the  acini,  an  appreciable  swelling  resulting.  This  explanation, 
however,  wih  not  suffice  for  even  a  majority  of  the  cases,  inasmuch  as  obstruc- 
tion is  more  frequently  absent  than  present.  The  tumor  comprises  a  capsule  and 
its  contents,  the  latter  consisting  of  pultaceous  material  mixed  with  epithelial 
scales.  Calcification  sometimes  occurs.  The  cysts  may  occur  in  the  skin 
covering  any  portion  of  the  body  except  the  limbs,  but  their  favorite  location 
is  the  scalp  and  the  external  genitals.  They  vary  in  size  from  a  pea  to 
a  small  orange. 

The  contents  of  these  cysts  are  Hable  to  decomposition,  when  a  peculiar  and 
extremely  offensive  odor  is  evolved.  Inflammatory  conditions  of  the  cyst  wall 
also  occur,  particularly  when  the,  cysts  are  situated  in  parts  exposed  to  injury. 
When  inflamed,  they  are  a  deep  purplish-red  color.  Suppuration  may  take 
place.  Simple  incision,  as  a  rule,  does  not  suffice  for  a  cure,  a  portion  or  all  of 
the  cyst  wall  remaining  and  leading  to  the  formation  of  fistulas  or  the  reproduc- 
tion of  the  entire  tumor. 


232  TUMORS 

Adenomas  of  the  thyroid  constitute  the  basis  of  one  of  the  forms  of  goiter. 
The}'  occur  as  encapsulated  tumors  in  one  or  both  lobes  of  the  glaiul,  vary 
greatly  in  size,  and  contain  vesicles  of  the  same  character  as  the  thyroid  gland 
itself.  Coalescence  of  the  vesicles  occurs  coincidentally  with  the  disappearance 
of  the  septa,  and  in  this  manner  a  cystic  bronchocele  is  formed.  The  cavity  of  a 
cyst  thus  formed  contains  fluid,  the  result  of  intracystic  hemorrhage.  The  fluid 
itself  often  contains  cholesterin.  Colloid  material  may  be  present  (colloid 
struma) .  Very  rarely  papillomas  may  be  found  springing  from  the  walls  of  the 
cyst. 

A  cystic  bronchocele  may  attain  large  proportions,  causing  pain  and  giving 
rise  to  dyspnea  from  pressure  on  the  trachea  in  cases  in  which  the  tumor 
descends  behind  the  episternal  notch.  When  the  descent  is  in  front  of  the 
sternum,  the  growth  is  sometimes  very  mobile. 

Adenomas  of  the  liver  when  fully  developed  occur  as  spherically  shaped 
and  encapsulated  tumors,  varying  in  size  from  a  hazelnut,  when  they  are 
single,  to  a  small  orange,  when  they  are  multiple.  They  may  be  situated  in 
almost  any  portion  of  the  liver.  They  may  be  a  bright  green  in  color,  due  to 
the  presence  of  bile,  or  a  dull  white.  They  are  made  up  of  sohd  columns  of 
cells  at  the  periphery  of  the  tumor  with  a  lumen  in  the  center.  In  a  case 
operated  on  by  the  author  the  growth  presented  to  the  naked  eye  a  striking 
resemblance  to  carcinoma. 

Prostatic  adenomas  consisting  of  enlarged  glands  in  the  prostate  are  of 
not  infreciuent  occurrence  late  in  hfe.  The  organ  becomes  increased  to  two 
or  three  times  its  normal  size,  and  this  increase  in  size,  when  it  occurs  in  con- 
nection with  the  collection  of  glands  situated  posteriorly  to  the  verumon- 
tanum,  may  cause  a  projection  into  the  lumen  of  the  urethra.  The  patency 
of  the  vesico-urethral  orifice  is  thus  interfered  with,  and  urinary  obstruction 
with  its  attendant  and  consequent  evils  follows. 

Carcinomas. — Malignant  neoplasms  arising  in  epithelium  are  called  car- 
cinomas, or  cancers.  A  malignant  tumor  springing  from  a  free  surface  covered 
with  epithelium  of  the  squamous  or  pavement  variety  is  called  an  epithehoma. 
When  the  growth  originates  in  the  epithelium  of  a  gland,  it  is  known  as  glandu- 
lar carcinoma. 

In  spite  of  the  widespread  distribution  of  the  epithelial  elements  from  which 
carcinomas  arise,  the  disease  shows  a  special  predilection  for  certain  localities, 
and  is  rarely  found  in  others. 

The  special  histologic  characteristic  of  carcinoma  consists  of  the  presence 
of  columns  of  cells,  which  on  section  present  under  the  microscope  the 
appearance  of  a  number  of  alveoli.  The  walls  of  these  alveoli  are  composed  of 
fibrous  tissue  in  which  blood-vessels  and  lymph- vessels  ramify,  and  the  spaces 
are  filled  with  epithelium  (Fig.  44).  The  cells  comprising  the  columns  par- 
take of  the  character  of  those  from  which  the  growth  originates.  The 
amount  of  fibrous  tissue  in  the  walls  of  the  columns  as  seen  under  the  micro- 
scope will  vary  greatly  between  the  hard  and  the  soft^variety. 

The  Infiltration  of  Carcinoma. — The  dangers  arising  from  the  presence  of 
carcinoma,  as  well  as  the  difficulties  of  dealing  with  it  surgically,  are  greatly 
enhanced  by  the  inability  of  even  the  skilled  pathologist,  with  the  aid  of  the 
microscope,  to  define  the  dividing  line  between  the  diseased  tissues  and  the 
surrounding  healthy  structure.  This  infiltrating  property  of  carcinoma  leads 
to  the  rapid  involvement  of  adjacent  parts,  whether  skin,  fat,  mucous  mem- 


CLASSIFICATION  233 

l)rane,  or  bone,  is  a  very  common  cause  of  death,  and  only  too  often  proves 
an  insnrniountable  l:)arrier  to  successful  surgical  intervention. 

Glandular  Infection. — The  free  distribution  of  lymph-vessels  on  the  sur- 
face of  the  body  and  within  the  secreting  glands  which  are  derived  from  this 
surface  forms  the  basis  for  a  free  communication  between  epithelial  growths  and 
the  lymphatic  glands,  and  for  the  conseciuent  infection  of  the  latter  when  carci- 
noma is  present.  Lymphatic  glands  thus  infected  may  attain  many  times  the 
size  of  the  original  growth.  The  readiness  with  which  lymphatic  glandular 
infection  arises  varies  with  the  susceptibilities  of  the  individual,  as  well  as  with 
the  anatomic  peculiarities  of  the  part  affected.  A  lack  of  knowledge  of  the 
extent  of  the  lymphatic  glandular  infection  renders  the  prognosis  after 
operation  very  uncertain. 

Dissemination. — In  addition  to  the  infiltrating  and  lymphatic-infecting 
properties  of  carcinomas,  their  malignancy  is  still  further  emphasized  by  their 
proneness  to  dissemination.  This  dissemination  occurs  through  the  medium  of 
secondary  deposits  which  have  their  origin  in  minute  portions  of  cancer  tissue. 
They  may  find  lodgment  in  any  of  the  organs  or  tissues  of  the  body,  may  be 
transported  as  emboli  by  the  lymph-  ,^  ^^^ 

vessels  and  blood-vessels  and  deposited  ^^=  '^  '^^  ^^^'^K 

in  situations  where  in  due  course  of  time  y<^^^^  ^H^^^^^^-. 

they  proliferate;  a  tumor  then  arises,  ^^^x 

which  has  exactly  the  same  histologic         ^^'^-"'''^ 
features  as  the  primary  growth.     When       ^ 

the  dissemination  is   widespread,  and      p'f  ^^ 

particularly  when  such  organs  as    the      ^-  '^ 

globe  of  the   eye,   ovaries,    brain,  and      ^  '^ 

vertebrae  are  the  seats    of  secondary       ^  '*,^^ 

deposits,  it  is  an  indication   that   emi-         ^?  "^^^ 

gration  of  the  cancer  emboli  has  taken  ^^ 

place  .  through    the    general  systemic 
circulation. 

Disseminated    infection    may    also 
take  place  without  the  aid  of  lymph-         ^ig.  44.-CARciNOMA^or  the  mammary 

vessels  or  blood-vessels,  as  in  the  case  of 

diffused  nodular  carcinoma  of  the  peritoneum.  Under  these  circumstances 
the  original  focus  of  disease  resides  in  an  abdominal  viscus,  the  implicated 
peritoneal  covering  of  which  gives  way,  so  that  the  epithelial  elements  of 
the  tumor  are  scattered  about  in  the  peritoneal  cavity  through  the  peristal- 
tic movements  of  the  intestines,  and  the  peritoneal  fluid. 

Degenerative  Changes. — The  absence  of  a  free  blood-supply  to  epithelial 
growths  leads  to  retrograde  changes  in  carcinomas,  the  chief  of  which  is  that 
known  as  colloid  degeneration.  In  colloid  degeneration  the  epithelial  cells 
making  up  the  columns  of  the  carcinomatous  structure  undergo  certain  changes 
which  result  in  a  jelly  like  transformation  of  the  cells.  These  changes  may  take 
place  so  rapidly  and  completely  in  certain  situations,  such  as  the  ovary,  the 
stomach,  and  the  breast,  that  cancerous  growths  in  these  organs  are  frequently 
referred  to  as  "colloid  carcinomas."  The  condition,  however,  is  simply  one  of 
degeneration  of  the  common  type  of  glandular  carcinoma. 

The  infective  properties  of  carcinoma  are  now  fairly  well  established. 
This  is  not  a  matter  of  surprise  when  the  readiness  with  which  epithelial  ele- 


234  TU.MORS 

merits  grow  when  accidentalh'  engrafted  is  considered.  The  most  important 
bearing  which  this  infective  character  has  in  the  work  of  the  practical  surgeon 
relates  to  the  care  that  should  be  exercised  in  operations  for  the  removal  of 
carcinomatous  growths  to  prevent  the  surfaces  of  the  wound  from  being  sown 
with  the  diseased  cells. 

The  Etiology  of  Carcinoma. — The  special  predilection  of  cancerous 
growths  to  attack  those  glandular  .structures  which  have  a  more  or  less  cUrect 
communication  with  the  outer  world,  such  as  the  mammae,  the  stomach  and 
rectum,  as  well  as  those  which  arise  directly  from  the  skin  surface,  has  suggested 
a  parasitic  origin  for  the  disease.  The  subject  is,  however,  stni  under  investi- 
gation, and  must  at  the  present  time  be  considered  sub  jiidice. 

While  there  are  reasons  for  believing  that  certain  congenital  local  predis- 
positions to  the  disease  exist  (moles,  nevi,  fleshy  warts,  etc.),  yet  it  should 
not  be  assumed  that  either  these  or  chronic  infiammator}^  lesions  are  the 
necessar\^  antecedents  of  cancer.  Traumata  have  also  been  considered  as 
being  efficient  causes  of  the  affection.  A  careful  study  of  the  statistics, 
however,  disproves  this  view  ( W  i  1 1  i  a  m  s) . 

Epithelioma. — Squamous-celled  carcinoma,  or  epitheUoma,  occurs  on  sur- 
faces covered  with  stratified  epithehum,  particularly  at  those  pomts  where  skin 
and  mucous  membrane  merge  into  each  other.  FamiUar  examples  of  the  latter 
tendency  are  found  in  the  Up,  the  vulva,  and  the  anus.  The  disease  arises  as 
a  prominent  isolated  growth  resembhng  a  wart,  as  a  small  ulcer  with  well- 
defined  and  infiltrated  margins,  and  as  a  fissure  with  more  or  less  firm  edges. 
The  histologic  characteristics  of  epithehoma  are  similar  to  those  of  glandular 
carcinoma,  the  surface  epithehum  mvading  the  growth,  or  the  ulcer  and  its 
mfntrated  margins,  in  the  shape  of  columns,  the  ceUs  of  which  retam  to  a  greater 
or  lesser  extent  the  characters  of  the  epithehum  from  which  they  sprmg.  Epi- 
thehal  pearls  are  formed  by  the  comification  of  the  flattened  cells  in  rapidly 
growing  cellular  cones.  Parts  that  are  the  seat  of  already  existing  disease  are 
apparently  more  haJjle  to  be  attacked  by  epithehoma.  As  examples  of  this 
may  be  cited  the  tongue  (leukoplakia  and  old  syphilitic  ulcers),  the  \ailva 
(leukoplakia),  and  chronic  ulcers  of  the  leg.  Disturbances  of  nutrition  due  to 
the  presence  of  scars  resulting  from  burns,  as  well  as  lupus  scars,  also  appear 
to  increase  the  liability  to  epithelioma. 

The  more  vascular  the  structures  adjacent  to  a  breaking  do^\ai  epitheli- 
oma, the  more  rapidly  the  infiltration  and  ulceration  extend.  Cartilage,  for 
mstance,  is  quite  exempt  from  invasion.  Occasionally  the  fungous  properties 
of  the  ulcer  predominate,  and  the  mfiltration  and  peripheral  ulceration 
proceed  more  slowly.  In  whatever  structure  or  situation  the  disease  occurs, 
however,  it  rapidly  destroys  life.  When  the  disease  mvolves  large  blood-vessels, 
these  are  opened,  and  death  from  hemorrhage  often  takes  place.  In  parts 
remote  from  large  vessels,  as  in  the  breast,  death  occurs  from  septic  and  anemic 
conditions  combined  (cachexia).  Death  from  inhalation  pneumonia  is  not 
infrequent  in  cases  in  which  the  cancerous  growth  is  adjacent  to  the  air-passages 
and  septic  material  is  inspired. 

Lymphatic  glandular  infection  is  the  most  serious  danger  which  threatens 
patients  with  epithelioma,  because  of  the  promptness  with  which  this  occurs, 
the  size  which  the  glands  attain,  and  the  difficulty  in  completely  removing 
these.  This  is  particularly  true  of  cases  of  epithelioma  of  the  tongue,  the  hp, 
the  scrotum,  and  the  penis. 


CLASSIFICATION  235 

Dissemination. — The  extent  to  which  this  occurs  bears  some  relation  to 
the  seat  of  the  tlisease.  This  is  due  in  part  to  the  fact  that  in  some  situations, 
as,  for  example,  the  larynx,  life  is  destroyed  before  opportunity  is  afforded  for 
dissemination.  On  the  other  hand,  this  does  not  hold  good  in  other  situations 
in  which  destruction  of  life  is  sometimes  delayed,  gland  infection  being 
extensive,  yet  dissemination  quite  exceptional,  as,  for  instance,  epithelioma 
of  the  scrotum. 

Treatment. — Clinical  experience  with  epithelioma,  as  in  the  case  of  all 
forms  of  malignant  disease,  emphasizes  the  supreme  importance  of  early  and 
complete  operative  removal  of  all  implicated  structures. 

DERMOIDS 

The  special  and  characteristic  feature  of  the  group  of  tumors  to  which  the 
term  "dermoid"  is  applied,  as  the  name  indicates,  is  the  presence  of  skin  and 
mucous  membrane  in  the  growth.  In  the  neoplasms  thus  indicated  the  skin 
or  mucous  membrane  is  formed  in  situations  where  these  structures  do  not 
exist  under  normal  conditions.     No  other  tissues  enter  into  their  composition. 

Four  genera  are  assigned  to  this  group,  as  follows:  (1)  sequestration  der- 
moids; (2)  tubulodermoids ;  (3)  hairy  moles;    (4)  ovarian  dermoids. 

Sequestration  Dermoids. — These  constitute  the  simple  form  of  this  group. 
As  the  name  implies,  they  arise  in  isolated  or  sequestrated  portions  of  skin, 
usualh"  in  the  lines  of  embryonic  coalescence.  A  dermoid  may  be  a  simple  skin- 
lined  recess ;  the  usual  form,  however,  is  that  of  a  globular  tumor  with  a  central 
cavity  the  lining  of  which  possesses  the  dermal  elements  of  true  skin. 

Dermoids  of  the  Face. — These  occur  in  situations  representing  the  site  of 
the  facial  fissures  in  the  embryo.  They  are  found  most  frequently  (1)  at  the 
outer  and  inner  angles  of  the  orbit;  (2)  in  the  upper  eyelid;  (3)  in  the 
nasofacial  sulcus;  (4)  as  dermoid  recesses  or  sinuses  at  the  site  of  the  inter- 
nasal  fissure. 

Dermoids  of  the  scalp  occur  most  frequently  over  the  anterior  fontanel 
and  at  the  occipital  protuberance.  In  either  of  these  situations  they  may  be 
mistaken  for  wens  or  meningoceles.  Dermoids  have  also  been  found  connected 
with  the  dura  mater,  a  circumstance  which  finds  its  morphologic  explanation  in 
the  fact  that  the  skin  and  dura  remain  practical^  in  contact  at  the  sites  of  the 
cranial  sutures,  even  for  a  year  or  more  after  birth,  particularly  in  the  neighbor- 
hood of  the  bregma  and  inion,  and  a  failure  of  ultimate  separation  as  the  bone 
fissure  closes  may  give  rise  to  a  dermoid. 

Dermoids  of  the  trunk  occur  strictly  in  the  regions  where  the  lateral  halves 
of  the  body  join  each  other,  namely,  on  the  line .  commencing  at  the  upper 
limit  of  the  cervical  vertebrae,  extending  along  the  middle  line  posteriorly, 
and  thence  through  the  perineum  and  upward  anteriorly  to  the  middle  of  the 
lower  lip.  Dermoids  are  rare  along  the  dorsal  portion  of  this  line,  with  the 
exception  of  sacral  cysts  and  coccygeal  sinuses.  The  latter  are  recesses  lined 
with  skin  and  running  almost  parallel  to  the  surface.  The  small  external 
opening  lies  at  the  bottom  of  a  so-called  postanal  dimple.  Hair  and  dirt 
accumulate  in  the  sinus  and  suppuration  may  occur.  A  sinus  of  this  kind  may 
be  mistaken  for  an  anal  fistula. 

Dermoids  of  the  thorax  are  very  rare.  They  may  occur  either  at  the  ante- 
rior aspect  of  the  sternum  or  within  the  chest  itself.     Only  the  former  are  of 


236 


TUMORS 


surgical  interest.  They  are  situated  near  the  junction  of  the  manubrium  with 
the  gladiohis,  at  the  site  of  a  small  dimple  or  recess  in  the  skin  sometimes  found 
in  this  situation.  A  dermoid  tlevelops,  though  rarely,  in  the  episternal  notch. 
Dermoids  of  the  Scrotum,  Testicle,  and  Labium. — Dermoids  of  the 
scrotum  have  been  found  in  such  close  relation  to  the  testicle  that  they  have 
been  reported  as  arising  from  the  latter.  It  is  probable,  however,  from  a 
morphologic  standpoint,  that  dermoids  of  the  testicle  are  very  rare  as  compared 
with  those  occurring  in  the  scrotum.  Dermoids  of  the  labium  are  very  common. 
In  a  case  operated  on  by  the  author  the  growth,  which  externally  was  only 
the  size  of  a  small  orange,  was  found  to  have  burrowed  deeply  into  the  thigh. 
A  similar  case  is  mentioned  by  Sutton. 

Implantation  cysts  are  of  interest  in  connection  with  the  study  of  dermoids. 

They  result  from  the  accidental  im- 
plantation of  portions  of  skin  or  of 
some  of  its  elements  (epithelium, 
hair-bulbs,  etc.)  into  the  subcuta- 
neous connective  tissue,  where  they 
become  engrafted  and  proliferate,  a 
cyst  resulting.  These  are  sometimes 
called  "  traumatic  dermoids."  They 
may  grow  to  the  size  of  a  hazelnut. 
Similar  cysts  of  traumatic  origin 
have  been  found  on  the  iris  and 
cornea. 

Tubulodermoids. — These  arise 
in  connection  with  one  of  the  em- 
bryonic canals  which  fail  to  disap- 
pear normally  at  birth.  Those 
which  may  remain  more  or  less  per- 
sistent after  birth  and  which  are  of 
special  surgical  importance  in  this 
connection  are  (1)  the  thyroglossal 
duct;  (2)  that  portion  of  embryonic 
intestine  extending  behind  the  anus 
called  the  postanal  gut;  (3)  the  bran- 
chial clefts. 

The  thyroglossal  duct  is  a  median 
offshoot  from  the  ventral  wall  of  the 
embryonic  pharynx,  from  which  the  isthmus  of  the  thyroid  is  derived.  In  the 
embryonic  state  the  duct  extends  as  far  upward  as  the  base  of  the  tongue  and 
bifurcates  laterally  in  the  direction  of  each  rudimentary  lobe  of  the  thyroid. 
Its  persistence  assumes  a  surgical  interest  in  connection  with  (1)  lingual 
dermoids;  (2)  median  cervical  fistulas;  (3)  accessory  thyroids. 

Lingual  dermoids  arise  in  the  tongue  and  occupy  a  central  position  in  that 
organ,  between  the  geniohyoglossi  muscles.  They  originate  in  the  lingual 
portion  of  the  thyroglossal  duct,  the  upper  end  of  which  has  become  obliterated. 
These  tumors  vary  greatly  in  size;  they  may  become  large  enough  to  interfere 
seriously  with  the  taking  of  food. 

Median  Cervical  Fistulas  (Fig.  45). — These  originate  as  retention  cysts 


Fig.  45. — Median  Cervical  Fistula  Associated 
WITH  A  Persistent  Thyroid  Duct. 


CLASSIFICATION 


237 


formed  in  a  persistent  thyroid  duct,  or  that  portion  of  the  thyroglossal  duct 
below  the  hyoid  bone.  A  median  swelUng  in  the  neck  commonly  precedes  the 
occurrence  of  glairy  or  mucous  discharge,  after  which  there  is  a  persistent 
sinus.  The  site  of  this  sinus  is  often  marked  l)y  a  cordlike  process  extending  up 
to  the  hyoid  bone.  The  lower  end  of  the  fistula  usually  terminates  in  a  thin- 
walled  sac  opening  on  the  free  surface  of  the  skin.  Upon  dissecting  out  this 
sinus  the  upper  end  may  be  found  to  be  obliterated  and  firmly  attached  to  the 
hyoid  bone.  The  sinus  may  also  be  bifurcated,  following  the  course  of  the  duct 
in  the  direction  of  the  lobes  of  the  thyroid.  The  lingual  duct,  or  that  portion 
above  the  h}-oid  bone,  may  persist  to  the  surface  of  the  tongue  (Fig.  46). 

Median  and  lateral  accessory  thyroid  bodies  may  occur  as  remnants  of 
the  thyroglossal  duct. 

Dermoids  of  the  Rectum. — These  occur  in  connection  with  the  embyronic 
postanal  gut,  which  also  gives  rise,  in  all  prob- 
ability, to  the  congenital  sacrococcygeal  tu- 
mors occasionally  observed.  The  variety  of 
dermoid  sometimes  found  between  the  hollow  of 
the  sacrum  and  the  rectum  (postrectal  der- 
moids) ,  which  may  attain  large  dimensions  and 
extend  upward  behind  the  pelvic  peritoneum, 
also  has  its  origin  in  this  obsolete  canal.  These 
growths  sometimes  contain  both  teeth  and  hair 
and  may  open  spontaneousl}'  in  the  perineum. 

In  addition  to  the  above  described  postrectal 
dermoids,  these  growths  have  been  found  grow- 
ing from  the  mucous  membrane  of  the  rectum 
as  pedunculated  tumors  (rectal  dermoids). 
They  may  protrude  from  the  anus  and  simulate 
either  rectal  polypi  or  hemorrhoids.  They  may 
contain  hair  and  teeth;  the  former  is  in  the 
shape  of  long  locks.  Dermoids  in  this  situa- 
tion should  not  be  confounded  with  ovarian 
dermoids,  which  sometimes  open  and  discharge 
into  the  rectum. 

Branchial  fistulas  and  cysts  have  their 
origin  in  either  one  or  more  of  the  four  em- 
bryonic branchial  clefts  of  the  human  fetus.  The  partial  or  complete 
persistence  of  one  or  more  of  these  clefts  results  in  congenital  cervical  fistulas 
(Fig.  47).  These  may  open  on  the  skin  surface  of  the  neck  or  in  the  pharynx; 
or  they  may  exist  as  complete  fistulas.  The  site  of  the  external  orifice  is  some- 
times marked  Isy  a  tag  of  skin  containing  yellow  elastic  cartilage  (con- 
genital cervical  auricle,  vide  infra).  The  fistulas  may  be  single  or 
multiple  and  lined  with  skin  or  mucous  membrane.  They  are  occasionally 
the  seat  of  suppuration  with  the  formation  of  an  abscess. 

The  persistence  of  the  portion  of  the  cleft  between  the  internal  and  the 
external  orifice  results  in  an  unobliterated  branchial  space,  a  true  retention 
dermoid  cyst  arising.  This  cyst  may  contain  mucus  if  the  external  portion  is 
obliterated,  and  the  sac  lined  with  mucous  membrane  continuous  with  that  of 
the  jjharynx;  or  if  the  internal  segment  of  the  cleft  is  obliterated,  the  sac  being 


Fig.    46. — Median  Cervical  Fistu- 
la.    (Diagrammatic,     showing 
THE  Relation  of  the    Parts.) 
1 ,  Hyoid  bone ;  2,  pyramid  of  thy- 
roid;   3,  abscess  sac;    4,  foramen  cae- 
cum;  5,   lingual    duct;    6,   epiglottis; 
7,  thyroid  cartilage;  8,  thyroid  gland; 
9,  trachea  (from    Sutton,    after  Mar- 
shall). 


238 


TUMOES 


continuous  with  the  epitheUal  structure  of  the  skin,  the  cystic  dilatation  will  be 
filled  with  epidermal  scales,  sebaceous  matter,  and  cholesterin.  In  the  ex- 
perience of  the  author  the  latter  is  the  more  common  variety.  Those  obliterated 
external]}-  but  openino;  internally  may  occur  as  diverticula  of  the  pharynx. 
Cervical  Auricles. — A  hereditary  influence  is  claimed  for  the  origin  of  these 
appendages.  Both  structurally  and  morphologically  the}'  are  identical  with 
the  normal  auricle  or  pinna,  and  consist  of  yellow  elastic  cartilage  and  muscle 
fiber  from  the  platysma,  covered  with  skin.  They  may  or  may  not  be 
associated  with  cervical  fistulas,  but  when  present  are  always  situated  in  the 
locations  affected  by  the  latter. 

A  congenital  fistula  sometimes  appears  leading  into  the  substance  of  the 

hehx  (auricular  fistula).  These  are 
deemed  hereditary  and  may  coexist 
with  branchial  fistulas.  They  are 
sometimes  found  in  the  lobule. 

Auricular  dermoids  arise  in  un- 
obliterated  skin-lined  spaces  left  be- 
tween the  tubercles  uniting  to  form 
the  auricle.  They  sometimes  occupy 
the  groove  between  the  pinna  and 
the  mastoid. 

Reduplication  of  the  tragus  some- 
times occurs  (accessory  tragus).  It 
may  occur  as  a  conical  projection  or  as 
a  pedunculated  process  of  skin  covered 
with  hair.  It  is  occasionally  associated 
with  defects  in  the  mandibular  fissure. 
Moles. — The  dermoid  patches 
known  as  moles  are  pigmented  and 
slightly  raised  above  the  level  of  the 
skin.  They  are  usually  covered  with 
hair.  They  are  very  vascular  and 
bleed  easily  if  injured,  or  in  case  of 
ulceration,  to  which  they  are  liable. 
The  tissue  immediately  underneath 
moles  is  arranged  in  alveoli,  such 
as  are  found  in  sarcomas  occurring 
in  connection  with  these  growths 
(alveolar  sarcomas).  In  fact,  the 
surgical  interest  manifested  in  these 
usually  innocent  tumors  is  centered  in  the  fact  that  later  in  life  they  are  liable 
to  become  the  starting-point  of  one  of  the  most  mahgnant  forms  of  sarcoma, 
namely  melanosarcoma. 

Moles  may  be  single  or  multiple,  they  are  sometimes  very  sensitive,  particu- 
larly those  which  occur  on  the  trunk.  The}'  may  occur  on  the  conjunctiva, 
where  they  are  sometimes  associated  with  the  embryonic  defect  of  the  eyelid 
known  as  coloboma. 

Teratomas  are  certain  irregular  and  conglomerate  masses  formed   almost 
exclusivelv  in  connection  with  the  vertebral  column  and  skull,  and  containing 


Fig.  47. — Congenital  Fistulas,  showing  Ori- 
fices OF  Persistent  Branchial  Fistulas. 
A,  Tympano-Eustachian  passage ;  B,  opening 
close  behind  the  angle  of  the  jaw,  and  anterior  to 
the  line  of  the  stern omast old  muscle;  this  open- 
ing is  sometimes  found  on  a  level  with  the  lobule 
of  the  pinna  and  slightly  posterior  to  it;  C,  this 
opening  occurs  very  constantly  in  the  situation  here 
shown,  i.  e.,  on  a  level  with  the  thyroid  space, 
close  to  the  anterior  border  of  the  sternomastoid ; 
D,  this  fistula  usually  opens  near  the  sternoclavi- 
cular articulation;  it  may  vary  somewhat  in  its 
relations  with  the  latter,  but  its  position  relative 
to  the  sternomastoid  muscle  is  rather  constant. 


CLASSIFICATION  239 

the  tissues  and  portions  of  viscera  ]:)cloiiging  to  an  immature  and  suppressed  fetus. 
They  occur  in  individuals  otherwise  normal  and  inchide  conjoined  twins,  super- 
numerary limbs,  and  acardiac  parasitic  fetuses.  They  are  mentioned  in  con- 
nection with  the  surgical  study  of  tumors  because  of  the  liability  of  confound- 
ing irregularl}-  shaped  tumors  with  dermoids. 

CYSTS  AND  PSEUDOCYSTS 
Cystomas  are  tumors  resulting  from  the  abnormal  dilatation  of  pre-existing 
tubules  or  cavities.     They  may  be  divided  into  (1)  retention  cysts;  (2)  tubu- 
locysts;  (3)  hydroceles. 

Retention  cysts,  as  the  name  implies,  result  from  the  obstruction  of  the 
duct  of  a  gland  and  the  accumulation  of  fluid  within  the  ducts  and  acini. 
When  the  obstruction  is  permanent,  the  gland  atrophies  and  is  replaced  by 
fibrous  tissue,  of  which  the  walls  of  the  simplest  form  of  cysts  are  composed. 
The  purest  form  of  cyst  occurs  in  connection  with  hollow  organs,  the  inner 
walls  of  which  are  provided  with  glands.  In  the  case  of  the  gall-bladder  the 
obstruction  may  be  due  to  impacted  gall-stones,  a  pancreatic  concretion, 
tumors,  etc.,  and  may  occur  in  the  cystic  duct,  in  the  common  duct,  in  Vater's 
diverticulum,  or  in  the  wall  of  the  duodenum  at  the  site  of  the  latter.  When 
the  obstruction  is  complete  and  permanent,  the  gall-bladder  may  atrophy 
if  the  obstruction  is  in  the  common  duct,  or  become  greatly  distended  with 
mucoid  fluid,  the  result  of  cholecystitis,  if  the  cystic  duct  is  the  seat  of  the 
obstruction  (dropsy  of  the  gall-bladder);  suppuration  may  follow  (empyema 
of  the  gall-bladder). 

Pseudocysts.— The  conditions  known  as  diverticula  and  pseudocysts  are 
conveniently  treated  of  in  this  connection.  They  include  the  intestinal,  vesical, 
and  pharyngeal  diverticula,  the  hernial  protrusions  of  synovial  membrane  from 
cavities  of  joints  known  as  synovial  cysts,  and  a  similar  condition  occurring 
in  connection  with  the  synovial  lining  of  a  tendon-sheath,  known  as  ganglion. 
Adventitious  bursae  are  also  to  be  classified  with  pseudocysts.  (For  intes- 
tinal, vesical,  and  pharyngeal  diverticula  see  Regional  Surgery,  Part  II.) 

Tubulocysts. — These  occur  in  the  so-called  functionless  ducts,  such  as  the 
vitello-intestinal  duct,  the  urachus,  and  the  remains  of  the  mesonephron 
(Wolffian  body).  Those  of  special  interest  to  the  general  surgeon  occur  in  con- 
nection with  the  above  mentioned.     (vSee  Regional  Surgery,  Part  II.) 

Synovial  Cysts.— These  may  occur  as  (1)  hernial  protrusions  of  the  lining 
of  a  joint;  (2)  bursae  in  the  neighborhood  of  joints;  (3)  hernial  protrusions  of 
the  synovial  covering  of  tendons.  The  first  have  been  frequently  observed  in 
connection  with  the  joints  of  the  hip,  knee,  ankle,  shoulder,  elbow,  and  wTist. 
Those  which  have  aroused  the  greatest  surgical  interest  have  occurred  in  con- 
nection with  the  knee-joint,  where  they  have  been  found  in  relation  with  the 
biceps,  the  semimembranosus,  or  the  heads  of  the  gastrocnemius  muscle. 
Cysts  have  been  found  at  some  distance  from  the  joints  from  which  they  arise, 
communication  being  maintained  by  a  very  narrow  channel.  They  are  liable 
to  arise  in  tuberculous  joints  and  are  due  to  increased  intra-articular  tension,  the 
synovial  membrane  being  forced  through  weak  spots  in  the  joint  capsule. 
Normal  bursae  in  the  neighborhood  of  joints  may  become  enlarged  and  establish 
a  communication  with  the  joint  cavity.  Synovial  cysts  connected  with  the 
knee-joint  are  likely  to  find  their  way  either  to  the  pophteal  space,  to  the 


240  TUMORS 

middle  of  the  calf  just  below  the  latter,  or  to  the  mner  side  of  the  leg  below  the 
head  of  the  tibia. 

It  may  be  said  of  these  cysts  in  a  general  way  as  they  occur  in  the  other 
locahties  named,  that  they  will  force  their  way  as  synovial  i3rojgctions  from 
the  joints  at  the  points  where  the  latter  are  least  protected  by  overlying  mus- 
cular structures,  and  thereafter  pass  in  the  direction  of  least  resistance  along 
the  intermuscular  planes.  Or  they  may  be  guided  by  the  margins  of  a  sharply 
defined  tendinous  structure,  as,  for  instance,  the  long  head  of  the  biceps  in  the 
case  of  a  synovial  cyst  of  the  shoulder. 

The  cyst  contents  may  be  clear  synovial  fluid,  or  in  the  case  of  diseased 
joints  it  may  be  turbid  and  contain  pus-cells;  or  true  pus  may  be  present. 

Ganglion. — The  cyst  wall  of  a  ganglion  consists  of  the  synovial  lining  of 
a  tendon-sheath  which  has  escaped  from  its  normal  environment. 

In  the  variety  known  as  simple  ganglion  the  cyst  appears  as  a  rounded, 
elastic,  sessile  swelling.  A  rather  common  situation  for  these  cysts  is  the 
back  of  the  carpus.  i\Iany  of  these,  however,  on  dissection  prove  to  be  diver- 
ticula from  a  carpal  joint,  from  which  it  is  often  exceedingly  difficult  to  differ- 
entiate them.  In  addition  to  the  above  named  familiar  location,  simple 
ganglions  are  met  with  in  the  sheaths  of  the  long  flexors  of  the  fingers,  on  the 
dorsum  of  the  foot,  and  on  the  outside  of  the  ankle.  The  fluid  contents 
resemble  grape  jelly. 

Compound  Ganglions. — These  occur  more  freciuently  in  connection  with 
the  flexor  and  extensor  tendons  of  the  carpus,  more  rarely  on  the  tendons  of 
the  peronei. 

This  variety  of  ganglion  is  of  far  greater  surgical  importance  than  the  fore- 
going. Extension  takes  place  for  variable  distances,  and  unexpectedly  wide 
dissections  are  sometimes  necessary  in  following  the  prolongations  of  the  cyst, 
which  may  pass  under  the  annular  ligament,  both  anteriorly  and  posteriorly, 
to  find  their  way  into  the  palm  or  along  the  extensor  tendons.  Crepitation  felt 
in  these  ganglions  is  due  to  the  presence  of  so-called  "  melon  seed"  bodies. 

Both  varieties  are  likely  to  recur  after  operation,  even  when  every  vestige 
in  sight  has  been  carefully  dissected  out.  In  the  case  of  the  simple  ganghons, 
this  is  due  to  the  fact  that,  though  they  burrow  in  and  between  the  tendons, 
they  really  spring  from  the  wrist-joint ;  in  the  case  of  the  compound  ganglions, 
to  the  fact  that  many  of  them  are  tuberculous  in  origin,  the  most  radical  meas- 
ures sometimes  being  inefficient  to  destroy  the  extensive  infective  process, 
so  that  after  repeated  recurrences  amputation  becomes  necessary. 

Bursae. — Bursal  sacs  may  form  in  any  part  of  the  subcutaneous  con- 
nective tissue  w^here  the  overlying  skin  is  subjected  to  intermittent  pressure. 
They  may  occur  in  any  portion  of  the  body  where  muscles  and  tendons  glide 
over  osseous  surfaces  or  in  situations  where  the  skin  lies  in  close  contact  with 
bony  prominences.  They  are  normally  present  in  certain  situations,  as,  for 
instance,  in  front  of  the  patella  and  behind  the  olecranon.  Adventitious 
bursae,  on  the  other  hand,  arise  in  situations  where  the  results  of  pressure  are 
a  pathologic  rather  than  a  physiologic  sequence  of  anatomic  conditions,  such 
as  in  clubfoot,  bunions,  etc.  Subtendinous  bursae  sometimes  communicate 
with  the  sheath  of  the  tendon  and  occasionally  with  the  cavity  of  a  neighboring 
joint. 

Bursal  sacs  are  thin  walled  with  smooth  inner  surfaces,  in  which,  as  a  rule. 


THE    DIAGNOSIS   OF  TUMORS  241 

epithelium  is  wanting.  They  contain  a  glairy  fluid  and  sometimes  loose  bodies. 
Their  formation  is  believed  to  be  brought  about  Ijy  the  rupture  of  connective 
tissue  between  the  movable  overlying  skin  and  the  solid  prominence  beneath. 
This  at  first  imperfectl}'  isolated  space  finally  assumes  definite  boundaries  and 
the  condensed  connective  tissue  becomes  a  smooth  sac  wall.  These  sacs  may 
occur  in  any  situation  where  pressure  is  exercised,  and  hence  bear  a  close  relation- 
ship to  the  occupation  of  the  individual.  The  most  frequent  forms  are  "house- 
maid's knee  "  "miner's  elbow,"  and  bunion.  The  first  occurs  in  persons 
whose  occupation  or  habit  leads  to  more  or  less  constant  kneeling.  The 
second  is  common  in  those  whose  occupation  in  close  quarters,  as  in  mining, 
leads  to  frequent  blows  on  the  elbows.  The  third  usually  results  from 
wearing  ill  fitting  shoes,  and  is  the  condition  commonly  observed  over  the 
enlarged  head  of  the  first  metatarsal  bone  in  hallux  valgus. 

Bursae  are  subject  to  inflammatory  conditions  (bursitis),  either  acute  or 
chronic.  An  acutely  inflamed  condition  demands  complete  rest  of  the  parts. 
Accumulations  of  fluid  may  occur,  requiring  either  systematic  pressure  to 
produce  absorption  or  incision  for  their  evacuation.  Suppurative  changes  are 
not  uncommon.  An  inflamed  bunion  may  involve  the  underlying  joint  and 
demand  excision  of  the  latter  or  even  amputation  of  the  toe. 

The  thyrohyoid  bursa,  or  that  lying  between  the  hyoid  bone  and  the 
thyrohyoid  meml^rane,  is  sometimes  the  seat  of  considerable  enlargement  and 
may  require  incision  and  drainage. 


THE  DIAGNOSIS  OF  TUMORS 

Even  the  existence  or  the  nonexistence  of  a  tumor  is  sometimes  difllicult  of 
aflarmation.  This  is  particularly  true  of  neoplasms  in  the  brain  and  spinal 
cord.  Dr.  Charles  K  .  Mills,  of  Philadelphia,  has  recently  called 
attention  to  the  R  o  n  t  g  e  n  ray  method  in  the  diagnosis  of  intracranial  neo- 
plasms. Tumors  of  the  abdominal  and  pelvic  cavities  sometimes  require  very 
close  attention  and  careful  watching  to  eliminate  the  possibility  of  an  accumu- 
lation of  intestinal  contents,  contractions  of  isolated  portions  of  muscular 
structures  (phantom  tumor),  the  existence  of  normal  and  ectopic  gestation, 
etc.,  as  sources  of  error.  In  the  case  of  neoplasms  easily  palpated,  as  well  as  in 
most  of  the  more  obscure  examples  in  which  both  subjective  and  objective 
symptoms  are  sometimes  contradictory  and  misleading,  the  question  of  differen- 
tial diagnosis  wall  frequently  present  many  difficulties.  The  history,  age  of  the 
patient  and  length  of  time  of  the  existence  of  the  tumor,  its  rate  of  growth, 
its  gross  physical  characters  and  situation,  its  freedom  of  movement  or  attach- 
ment to  surrounding  and  overlying  structures,  its  relations  to  these,  the 
question  of  lymphatic  iuA^olvement  or  visceral  complications,  the  presence  of 
metastases,  the  microscopic  characters  of  sections  removed  for  examination  in 
the  differentiation  of  benign  and  malignant  growths,  the  results  of  ex- 
ploratory operation  and  the  outcome  of  therapeutic  tests  in  the  exclusion  of 
syphilitic  lesions — all  these  are  of  the  greatest  importance  in  connection 
with  the  diagnosis  of  neoplasms. 


17 


242  TUMORS 

TREATMENT  OF  TUMORS 

In  a  general  wa}'  it  may  be  stated  that  the  only  trustworthy  method  of 
dealing  with  a  tumor  is  to  effect  its  removal  or  destruction.  There  can  be 
no  two  opinions  as  to  the  advisability  of  promptly  attacking  any  malignant 
growth,  and  removing  it,  together  with  as  much  of  the  surrounding  structures 
as  safety  will  permit.  Amputation  of  a  part  involved  in  a  malignant  growth 
should  always  be  given  the  preference  over  simple  excision.  Benign  tumors  may 
be  removed  whenever  they  become  a  source  of  annoyance,  inconvenience,  dis- 
comfort, or  deformity.  In  the  event  of  their  becoming  a  source  of  ill  health 
even  to  a  slight  extent,  or  a  menace  in  the  future,  their  removal  is  demanded. 


SECTION  VII 

LABORATORY  AIDS  IN  SURGICAL  DIAGNOSIS  AND 

PROGNOSIS 

The  use  of  laboratory  procedures  as  practical  aids  in  the  diagnosis  and 
prognosis  of  disease  is  comparatively  modern,  and  their  value  has  become  so 
important  that  a  consideration  of  their  significance  and  of  the  detail  of  their 
technic  has  earned  a  place  in  every  text-book. 

Successful  surgery  demands  prompt  and  accurate  diagnosis,  and  to  this 
end  laboratory  examinations  frequently  offer  conclusive  proof  or  corroborative 
evidence  of  much  value.  With  the  great  advances  in  surgical  skill  and  the 
consequent  improved  statistics  of  surgical  procedure,  the  question  of  prognosis 
has  also  become  more  important,  and  laboratory  aids  form  no  mean  part 
in  reaching  conclusions  in  this  regard.  The  brilliant  outcome  of  laboratory 
diagnostic  methods  in  some  cases  may  lead  the  novice  to  attempt  to  make 
a  definite  diagnosis  with  the  microscope  and  test-tube  at  the  expense  of  clin- 
ical methods.  This  is  a  grave  error— the  diagnosis  must  be  made  at  the  bed- 
side, and  the  results  of  laboratory  work  considered  for  what  experience  teaches 
they  are  worth,  just  as  the  clinical  signs  and  symptoms  are  considered. 

Pathologic,  bacteriologic,  and  chemic  technic  must  be  shorn  of  every  detail 
not  absolutely  necessary,  in  order  to  commend  itself  to  the  busy  practical 
worker,  who  is  interested  solely  in  the  result,  and  not  in  the  method  of 
investigation.  The  surgeon  seeks  aid  in  diagnosis  and  prognosis;  he  is  in- 
terested in  the  outcome  of  the  laboratory  help,  and  the  methods  that  meet  with 
his  approval  are  those  which  are  easily  and  quickly  executed,  often  at  the 
expense  of  absolute  accuracy,  as  long  as  they  are  sufficiently  precise  to  meet 
clinical  practical  purposes. 

The  research  laboratory  worker  should  be  a  scientist;  for  him  absolute 
accuracy  is  the  keynote  of  success,  without  which  his  results  merit  no  confidence. 
He  must^  modify  his  absolutely  accurate  method,  in  order  that  it  may  appeal 
to  the  clinician  as  a  practical  procedure,  the  results  of  which  justify  the  work 
required.  This  demand,  being  of  comparatively  recent  date,  has  not  had  the 
attention  from  teachers  that  it  deserves,  as  the  following  examples  will 
illustrate  :  Teachers  and  text-books  advocate  the  spreading  on  the  thin 
microscopic  cover-glasses  of  sputum,  pus,  blood,  or  any  other  substance  which 
is  to  be  dried  on  a  carrier  for  subsequent  staining.  These  small  films  of  glass 
are  difficult  to  handle,  are  easily  broken  in  the  manipulation  of  staining, 
washing,  and  drying,  and  present  a  limited  surface  for  investigation.  The 
microscopic  slide  should  be  used  for  this  purpose.  Its  advantages  are  obvious. 
A  chemic  procedure  often  presents  the  details  of  complex  graphic  formulas  of 
not  the  slightest  interest  to  the  practical  worker,  while  the  specific  directions 
given  for  the  test  are  so  lax  as  positively  to  invite  error. 

243 


244  LABORATORY    AIDS    IN    SURGICAL    DIAGNOSIS 

The  following  is  a  brief  summary  of  the  examinations  useful  in  surgical 
diagnosis  and  prognosis,  with  a  description  of  the  technic  in  the  more  important 
ones : 


Pathologic  examinations. 


Blood. 
Urine. 


Bacteriologic  examinations. 

Chemic  examinations. 

Specific  examinations <|  Sputum. 

Gastric  contents. 

Aspirated  fluids. 

PATHOLOGIC  EXAMINATIONS 

The  following  remarks  must  necessarily  be  limited  to  the  preservation  and 
preparation  of  specimens  for  examination,  whereas  the  descriptions  of  the 
different  gross  and  microscopic  pathologic  tissue  changes  met  with  in  surgery 
are  detailed  elsewhere.  For  more  minute  data  of  the  latter  the  reader  is 
referred  to  the  many  admirable  text-books  on  pathology. 

Gross  Pathology  in  surgical  diagnosis,  or  what  can  be  learned  by  inspec- 
tion, palpation,  etc.,  belongs  to  the  clinical  consideration  and  can  be  dis- 
missed here.  The  gross  consideration  of  pathologic  specimens  removed  by 
operation  is  an  important  matter,  and  their  proper  manijDulation  immediately 
after  removal  not  only  allows  a  more  critical  inspection,  but  also  preserves  them 
for  future  examination  and  demonstration.  The  old  method  of  washing  the 
specimen  in  running  water  to  remove  the  blood  and  then  preserving  in  alcohol, 
doubtless  prevents  decomposition,  but  shrinks  and  decolorizes  it  to  such  an 
extent  that  recognition  is  often  impossible.  The  following  procedure  is  therefore 
recommended :  As  soon  as  possible  after  the  removal  of  the  specimen,  the  small 
pieces  for  histologic  examination  should  be  excised  and  placed  in  their  proper 
fixative,  and  then  the  whole  specimen  should  be  immersed  in  No.  1  Pick's 
solution  without  previous  washing  and  before  the  surfaces  have  become  dry.  It 
is  rarely  necessary  to  make  incisions,  except  in  very  large  specimens.  Open 
cavities  should  be  stuffed  with  absorbent  cotton  to  preserve  contour.  Closed 
cavities  containing  fluid  may  be  aspirated  and  injected  with  the  preservative. 
Cross-sections  of  tumors  and  organs,  especially  the  kidney,  usually  show  better 
if  made  after  the  specimen  is  taken  out  of  No.  1  solution. 

No.  1  Pick's  Solution: 

50  grams  artificial  Carlsbad  salts. 
1000  c.c.  distilled  water. 
Dissolve,  filter,  and  add 

50  c.c.  Schering's  formalin. 

This  solution  should  be  freshly  prepared  for  each  specimen  in  ample  amount. 
Specimens  look  grayish-red  and  should  be  kept  in  the  solution  from  one  to  five 
days  according  to  shape  and  size.  They  are  then  placed  in  85  per  cent  alcohol 
from  two  to  six  hours,  and  the  natural  color  returns. 

The  specimen  is  now  transferred  to  No.  2  solution  in  a  large  specimen  jar, 
and  after  remaining  there  for  a  number  of  days  it  may  be  placed  for  permanent 
preservation  in  a  smaller  jar  containing  the  same  fluid. 


PATHOLOGIC    EXAMINATIONS  245 

No.  2  Pick's  Sohitinn: 

300  grams  potassium  acetate  cryst.  (c.  p.). 
1000  c'.c.  distilled  water. 
Dissolve,  filter,  and  add 

(100  c.c.  pure  glycerin. 
For  luuscvilar  tissue  reduce  the  amount  of  potassium  acetate  to  150  grams. 

If  this  method  is  carefully  carried  out,  it  is  astonishing  how  well  specimens 
are  preserved  in  both  color  and  contour. 

Pathologic  Histology  is  often  most  important  in  surgical  diagnosis, 
and  frequently  has  a  direct  bearing  on  the  prognosis.  The  successful  outcome 
of  the  examination  may  be  largely  dependent  on  the  prompt  and  proper  care 
given  the  specimen,  and  for  this  reason  it  should  be  placed  in  the  fixative 
as  soon  as  possible  after  its  removal  from  the  body. 
The  usual  examinations  for  diagnosis  are  as  follows: 

Small  pieces  of  pseudoplasm  excised  for  diagnosis. 
Small  pieces  excised  from  diseased  tissue  which  has  been  removed 
by  operation. 
When  small  pieces  of  pseudoplasm  are  excised  for  diagnosis,  the  method 
selected  for  preparing  the  specimen  for  microscopic  examination  will  depend 
on  the  time  available  for  this  purpose. 

If  the  specimen  is  removed  at  the  first  stage  of  the  operation,  and  the 
patient  is  kept  under  an  anesthetic  pending  the  result  of  the  microscopic 
examination,  or  when  rapid  work  is  necessary  for  other  reasons,  the  sections 
must  be  made  with  the  freezing  microtome.  While  the  technic  of  frozen  sec- 
tions has  been  much  improved,  the  pictures  which  they  present  are  satisfac- 
tory only  when  the  structure  is  a  clearly  defined  one,  and  continuous  use  of 
the  method  will  demonstrate  how  frequently  its  results  are  unsatisfactory  or 
meaningless.  It  is  far  preferable  to  use  one  of  the  embedding  methods  when 
time  allows,  as  the  sections  are  thinner  and  the  microscopic  picture  is  much 
more  satisfactory.  When  the  surgeon  clearly  understands  the  decided  advan- 
tages of  the  latter  method,  the  occasions  for  the  use  of  the  freezing  microtome 

will  be  rare.  .      ,      ,   ,, 

Brief  Instructions  for  Making  Frozen  Sections.— The  simple  table 
microtome  with  a  strongly  made  freezing  chamber,  the  vents  of  the  latter 
being  large  enough  to  prevent  clogging  and  back  pressure,  and  the  usual 
chisel-edged  spade-like  knife  make  a  satisfactory  apparatus.  The  so-called 
student's  freezing  microtome  made  by  Jung,  of  Heidelberg,  as  shown  m 
Fig.  48,  is  inexpensive  and  far  superior  to  anything  in  the  home  market. 
It 'can  be  imported  by  any  one  of  the  supply  shops.  Compressed  carbonic  acid 
gas  as  a  "  freezing  mixture"  is  convenient,  rapid,  certain,  and  cheap  as 
compared  with  ether  or  rhigolene.  The  steel  cylinder  containing  the  hquid  CO^ 
can  be  obtained  in  every  city,  and  is  usually  loaned  without  charge  to  the 
-  purchaser  of  the  contents.  As  shown  in  the  accompanying  cut,  the  cylinder 
should  be  inverted  and  the  outlet  connected  with  the  freezing  chamber  by 
means  of  heavj^  rubber  pressure  tubing  wired  to  the  nipples.  The  valve,  which 
should  be  on  a  level  with  the  freezing  chamber,  must  be  opened  carefully,  so 
as  not  to  burst  the  rubber  tubing.  Permanent  hospital  equipments  should  not 
be  made  with  iron  pipe  for  obvious  reasons. 

A  small  piece  of  the  fresh  specimen,  not  more  than  4  or  5  mm.  thick,  is 
placed  on  the  plate  of  the  freezing  chamber  in  a  few  drops  of  water  and  quickly 


246 


LABORATORY    AIDS    IN    SURGICAL    DIAGNOSIS 


frozen.  After  a  few  seconds,  a  numl3cr  of  sections  are  rapidly  cut  and 
removed  from  the  knife  by  immersing  it  in  water.  A  few  of  the  best  sections 
are  placed  for  two  minutes  in  4  per  cent  formalin,  for  two 
minutes  in  95  per  cent  alcohol,  for  two  minutes  in  aljsolute 
alcohol,  and  then  transferred  to  water.  They  are  then 
stained  with  rnethylene-blue  (saturated  acjueous  solution, 
half  strength)  for  ninety  seconds,  washed  in  water,  and 
mounted  in  glycerin.  Thus  the  slide  bearing  a  present- 
able section  can  be  under  the  microscope  within  twelve 
minutes  after  the  excision.  More  rapid  methods  are  avail- 
able, but  the  results  are  usually  most  unsatisfactory. 

Brief  Instructions  for  Making  Embedded  Sections. — 
Specimens  embedded  in  celloidin  or  paraffin  may  be  sec- 
tioned on  one  of  the  many  microtomes  in  the  market,  the 
selection  of  the  instrument  depending  largely  on  the  amount 
of  work  to  be  done  and  on  the  expenditure.  For  diagnos- 
tic purposes,  where  the  paraffin  method  is  used,  the  stu- 
dent's microtome  shown  in  Fig.  48,  the  use  of  the  freezing 
chamber  being  omitted,  is  an  excellent  instrument  and  can 
be  used  for  all  purposes. 

The  paraffin  method  usually  leads  to  the  best  results, 
and  the  following  description  will  be  hmited  to  it:* 

A  small  piece  of  the  tissue  to  be  examined  (about  1  cm. 
square,  and  3  mm.  thick)  is  placed  successively  in  the 
following  solutions: 

6  hours  or  more 4  per  cent  formalin. 

6  hours  or  more 80  per  cent  alcohol. 

6  hours  or  more 95  per  cent  alcohol. 

6  hours  or  more absolute  alcohol 

6  hours  or  more chloroform. 

6  hours  or  more saturated  solution  paraffin 

in  chloroform. 
1  hour  or  more paraffin  bath. 


Tii 


Fig.  48. — Freezing  Microtome  Made  by  Jung,  of  Heidelberg, 
WITH  Liquid  Carbonic  Acid  Gas  Freezing  Attachment. 


It  is  then  embedded 
in  paraffin,  cooled,  at- 
tached to  the  object- 
holder,  and  cut.  The 
paraffin  bath  is  better 
replaced  by  a  small  incu- 
bator kept  at  a  steady 
temperature  by  a  ther- 
mostat, according  to  the 
melting-point  of  the  par- 
affin employed. 

The  cut  sections  are 
placed  on  the  surface  of 
a  dish  of  warm  water, 
in  order    to    remove    all 


*For  a  more  detailed  account  of  this  and  other  methods,  the  reader  is  referred 
to  Mallory  and  Wright's  "Pathological  Technique,"  3d  edition,  1904.  W.  B.  Saunders 
&  Co.,  Publishers. 


BACTERIOLOGIC    EXAMINATIONS 


247 


wrinkles,  and  the  best  ones  are  then  attached  to  the  microscopic  sUdes, 
which  hiu-e  previously  been  coated  with  a  glycerin  albumen  mixture  (equal 
parts  of  white  of  egg'  and  glycerin  thoroughly  beaten  and  filtered,  to  which 
a  few  drops  of  carbolic  acid  may  be  added  as  a  preservative).  The  excess 
is  drained,  and  when  the  slide  is  dry,  it  is  placed  in  the  small  incubator  at  about 
58°  C.  for  several  hours.  This  will  firmly  attach  the  section  to  the  slide.  The 
paraffin  is  now  removed  by  passing  the  slide  through  two  or  three  changes  of 
xylol,  followed  by  absolute  alcohol  and  then  by  95  per  cent  alcohol. 

I^Iany  simple  and  elaborate  staining  methods  are  now  in  use  to  serve  par- 
ticular purposes,  but  for  general  histologic  work  the  hematoxylin  and  eosin 
method  serves  most  purposes.  The  section  attached  to  the  slide  is  now  placed 
in  water,  and  then  stained  from  two  to  thirty  minutes  in  Delafield's 
hematoxylin.  Better  results  are  oftentimes  achieved  by  diluting  this  stain 
with  water  and  staining  the  specimen  for  a  longer  period.  Delafield's  hema- 
toxylin solution  is  difficult  to  make,  and  that  made  by  Grlibler  can  be 
purchased  in  anv  supplv  shop.  After  the  specimens  have  been  stained  they 
are  washed  for  several  hours  in  frequent  changes  of  water,  or  in  running  water 
for  twenty  minutes;  they  are  then  placed  in  a  0.2  per  cent  aqueous  solution 
of  eosin  for  about  five  minutes.  This  is  followed  by  two  or  three  changes  of  95 
per  cent  alcohol  to  remove  the  excess  of  eosin  and  for  purposes  of  dehydra- 
tion. The  specimen  is  now  cleared  in  oleum  origani  and  mounted  in  Canada 
balsam.  As  stated  above,  the  microscopic  pictures  found  in  the  different 
pathologic  lesions  are  detailed  elsewhere. 

BACTERIOLOGIC  EXAMINATIONS 

These  examinations  form  an  important  item  in  laboratory  aids  in  diagnosis, 
and  the  heading  is  placed  among  these  for  completeness,  but  for  details  the 
reader  is  referred  to  the  section  on  the  subject.  The  bactenologic  investiga- 
tions of  practical  value  in  clinical  diagnosis  are  comparatively  simple  and  should 
be  in  general  use  more  than  thev  are.  They  consist  chiefly  m  direct  micro- 
scopic examination  of  secretions  or  excretions  for  bacteria,  or,  if  the  organisms  are 
not  present  in  sufficient  numbers  or  the  morphology  is  uncertain,  m  examination 
of  cultures.  Direct  examinations  are  quickly  made  and  the  advantage  of  shdes 
instead  of  cover-glasses  is  again  emphasized.  For  cultures,  a  small  incubator 
heated  by  gas  or  electricitv  should  be  employed.  It  is  inexpensive,  occupies 
but  little  room,  and  is  easily  cared  for.  If  gas  is  used,  a  Dunham  regulator 
(Fig.  2)  is  all  that  is  required,  the  additional  gas-pressure  regulator  being 
unnecessarv  for  clinical  purposes.  All  varieties  of  culture-media  may  be  ob- 
tained from  any  laboratorv,  or  from  Parke,  Davis  &  Co.  Petri  dishes  for  plate 
cultures  are  easily  sterilized  in  the  apparatus  which  every  surgeon  has  m  con- 
stant use.  With  the  conveniences  at  home,  the  surgeon  is  likely  to  avail  himself 
of  them  more  frequentlv  than  if  specimens  are  sent  off  to  a  laboratory.  To  cite 
a  few  pertinent  practical  examples:  ]\Iiddle-ear  secretion  containing  strepto- 
cocci is  followed  by  mastoid  involvement  in  over  90  per  cent  of  the  cases, 
whereas  staphylococci,  pneumococci,  and  colon  bacilli  show  totally  different 
figures.  In  other  regions  of  the  body  a  streptococcus  infection  usually  calls  tor 
more  extensive  surgical  interference  than  the  presence  of  other  organisms. 
The  value  of  a  culture  from  the  throat  to  differentiate  the  bacillus  of  diphtheria 


248  LABORATORY   AIDS    IN    SURGICAL    DIAGNOSIS 

from  streptococcus,  and  the  necessity  of  a  microscopic  examination  to  dis- 
tinguish a  gonorrheal  ophthalmia  from  a  benign  one,  need  no  more  than 
brief  mention. 

CHEMIC  EXAMINATIONS 

The  application  of  chemic  analysis  as  a  clinical  laboratory  diagnostic  aid 
probably  owes  its  delayed  advancement  to  the  time  demanded  by  this  work 
and  the  fact  that  the  medical  student  was  formerly  not  taught  chemic  technic 
to  any  extent.  The  great  advances  in  recent  years  have  brought  about  a 
necessary  change,  and  a  good  chemic  laboratory  in  the  medical  school  is 
the  result.  Chemic  methods  of  value  to  the  surgeon  are  mentioned  under 
the  head  of  Specific  Examinations. 

EXAMINATION  OF  THE  BLOOD 

It  is  within  comparatively  recent  years  that  hematology  has  emerged  from 
its  theoretic  state  into  a  science  of  practical  utility  to  the  clinician,  and  today 
it  stands  as  a  factor  of  prime  importance  to  the  surgeon  in  diagnosis  as  well  as  in 
prognosis.  The  technic  of  a  thorough  blood  examination  has  also  been  simpli- 
fied to  such  an  extent  that  it  is  within  the  reach  of  every  one.  If  a  blood 
examination  is  worth  making  at  all,  it  is  worth  making  not  only  well  but  thor- 
oughly, and  the  methodic  worker  is  the  one  who  does  not  overlook  pathologic 
lesions  not  suspected  by  the  cHnical  history.  For  example,  the  mere  leukocyte 
count  of  45,000  has  seemed  to  indicate  an  inflammatory  process  in  the  hver 
resulting  in  abscess.  The  surgeon  about  to  operate  and  not  satisfied  with  the 
appearance  of  his  patient  has  the  blood  examined  by  an  expert  hematologist, 
with  the  result  that  a  diagnosis  of  acute  lymphatic  leukemia  is  made,  which 
explains  leukocytosis,  the  patient's  prostration,  pain,  temperature,  and  area  of 
dullness,  and  practically  excludes  the  presence  of  pus. 

TECHNIC  OF  EXAMINATION  OF  THE  BLOOD 

A  complete  routine  blood  examination  is  urgently  recommended  in  every 
instance,  but  some  special  work  is  reserved  for  special  cases  requiring  the  same. 
This  is  not  the  place  for  a  detailed  consideration  of  technic,  but  the  subject  will 
be  briefly  outlined.* 

Routine  examination  should  include  the  following : 

Estimation  of  the  amount  of  hemoglobin. 

Count  of  red  corpuscles  and  leukocytes  in  1  c.mm.  of  blood. 

Differential  count  of  leukocytes  and  examination  of  stained  specimen. 
Exceptional  procedures  are 

lodophilic  reaction. 

Cryoscopy  of  the  blood. 

Blood  cultures. 

A  number  of  these  procedures  are  purposely  omitted  in  the  present 
study,  as  they  belong  to  internal  medicine  rather  than  surgery. 

*  The  reader  is  referred  to  Cabot,  "Clinical  Examination  of  the  Blood,"  or  DaCosta, 
"Clinical  Hematology." 


EXAMINATION    OF    THE    BLOOD 


249 


Hemoglobin. — The  estimation  of  the  amount  of  coloring-matter  is,  from 
a  scientific  ])()int  of  view,  the  least  satisfactory  procedure  in  present  day  hema- 
tology, but  it  must  be  employed  in  the  absence  of  better  clinical  means.  Of  the 
numerous  methods  in  use,  the  ])are  hemoglobinometer  and  the  Tallqvist 
scale  are  worthy  of  mention. 

The  Dare  hemoglobinometer,  as  shown  in  the  accompanying  illustration, 
is  the  best  instrument  in  use.     The  undiluted  blood  is  drawn  by  capillary 


Fig.  49. — The  Dare  Hemoglobinometer. 

attraction  between  two  glass  plates  which  form  a  chamber  of  measured  thick- 
ness. The  color  is  then  compared  with  the  color  plate,  the  two  are  matched, 
and  the  result  read  from  a  conveniently  placed  scale. 

The  Tallqvist  scale  is  not  nearly  so  accurate  as  the  above  method,  but  is 
far  preferable  to  no  determination  of  hemoglobin  at  all.  It  consists  of  a  series 
of  standard  tints  representing  a  scale  from  10  to  100  by  tenths,  and  is  used  in 


Fig.  50. — Thoma-Zeiss  Hemocytgmeter  for  Dilutions  of  1  :  100  and  1  :  200. 

daylight.  A  large  drop  of  blood  is  received  on  a  piece  of  white  filter-paper, 
strips  of  which  accompany  the  color  scale,  and  is  then  compared  with  the  scale. 

In  the  estimation  of  hemoglobin  the  arbitrary  normal  is  placed  at  100  per 
cent,  but  our  city  dwellers  rarely  show  this  figure.  The  Fleischl  appa- 
ratus, of  which  there  are  many  in  use,  shows  the  lowest  readings. 

Count  of  Red  Corpuscles  and  Leukocytes. — The  fresh  blood  is  diluted 
in  proportion  of  1:100  or  1:200,  the  corpuscles  in  a  given  cubic  space 
are   counted  under  the  microscope,  and  thus  the  number  of  corpuscles  in 


250 


LABORATORY    AIDS    IX    SURGICAL    DIAGNOSIS 


1  c.mm.  is  computed.  For  the  purpose  of  dilution,  the  Thoma  pipet  made  by 
Zeiss,  as  shown  in  the  illustration,  is  the  best  one.  The  blood  is  drawn  to  the 
figure  1,  and  after  the  excess  is  carefully  removed  from  the  tip  of  the  pipet,  it  is 
filled  to  the  mark  101  with  Toisson's  solution,  the  resulting  dilution  being 
1  :  100.     Toisson's  solution  is  made  as  follows: 

Methyl  violet  5  B ' 0.012 

Sodium  chlorid 0.5 

Sodium  sulfate 4.0 

Glvcerin,  pure   15.0 

Distilled  water 80.0 

After  the  dilution  in  the  pipet  is  thoroughly  mixed  by  means  of  the  contained 
small  glass  ball,  a  number  of  drops  are  blown  out  and  a  small  one  is  placed  in 
the  center  of  an  absolutely  clean  Thoma-Zeiss  containing  chamber  and 
quickly  covered  with  the  cover-glass  of  the  apparatus,  the  presence  of  New- 
ton's  rings    indicating    proper  contact.     The  counting   chamber  having  the 


B 


0.10  Omm. 

!■    11    1 

Fig.  51. — Thoma-Zeiss  Counting  Chamber. 

A,  Cross-section.     B,  Plan  view.     1,  Glass  slide;  2,  2',  tinted  glass  for  support  of  cover;  3,  cover-glass; 

4,  circular  ruled  glass  disk.     Actual   chamber  for  blood  is  between  3  and  4. 


Elzholz  ruling,  as  shown  in  Fig.  52,  is  preferable  to  that  having  the  Thoma 
ruling,  as  both  the  red  corpuscles  and  the  leukocytes  can  be  counted 
in  the  same  specimen.  A  good  plan  is  to  count  the  red  corpuscles  in 
the  small  scjuares  marked  with  dots  in  the  illustration,  and  all  the  leuko- 
cytes in  the  entire  ruled  surface.  The  counting  chamber  is  then  cleaned  and 
the  procedure  repeated.  In  this  w^ay  the  red  corpuscles  in  120  small  squares 
have  been  counted  (for  example,  1140),  and  the  number  in  1  c.mm.  can  be 
figured  as  follows : 

1140  X  (dilution)  100  X  (cubic  space  of  square)  4000  ^  (squares  counted)  120  = 
3,800,000  red  corpuscles  in  1  c.mm.  of  blood. 

The  normal  figures  usually  quoted  are,  males  5,000,000,  females  about  4,500,000, 
but  perfectly  healthy  persons  deviate  from  this  rule.     The  leukocytes  in  the 


EXAMINATION    OF    THE    BLOOJ) 


251 


equivalent  of  7200  small  squares  have  been  counted  (for  example,  144),  and 
the  number  in  1  c.mm.  can  be  estimated  as  follows: 

144  X  100  X  4000  ^  7200  =  8000  leukocytes  in  1  c.mui.  of  Ijlood. 
A  table  of  5000  blood  specimens  shows  the  following  figures  for  healthy  adults: 
Leukocytes  in  1  c.mm.  of  blood  from  5200  to  9600,  the  average  })eing  0700. 
Differential  Count  of  Leukocytes  and  Microscopic  Examination  of 
Stained  Specimens..— 'iliis  procedure  is  of  the  greatest  importance  in  the 
diagnostic  significance  of  hematology,  and  it  is  the  feature  which  is  most 
frequently  neglected  on  account  of  its  supposed  difficulty  and  expenditure 
of  time.  As  a  matter  of  fact,  the  new  staining  methods  and  some  experience 
make  it  the  least  tedious  of  the  different  steps  in  a  routine  blood  examination. 


Fig.  52. — Elzholz  Ruling  of  Counting  Chamber.     (Magnified  30  times.) 
Red  corpuscles  are  counted  in  the  squares  marked  with  dots.     Leukocytes  are  counted  in  entire  ruled  space. 

The  smears  are  best  made  on  slides  instead  of  cover-glasses,  and  a  Httle  prac- 
tice results  in  thin  and  even  specimens  in  which  the  corpuscles  have  not  been 
injured  by  pressure.  For  the  purpose  of  fixing  and  staining,  these  are  placed 
for  several  minutes  in  a  covered  vessel  containing  Wright's  stain,  then 
removed  and  a  drop  or  two  of  water  added  to  dilute  the  stain  adhering  to  the 
specimen.  This  is  allowed  to  remain  two  or  three  minutes,  and  the  specimen 
is  then  washed  in  water  until  it  has  a  yellowish-pink  color.  The  process  of 
decolorization  and  differentiation  is  the  objection  to  Wright's  stain,  but 
this  can  be  avoided  by  making  a  mixture  of  Jenner's  stain,  2  parts, 
and  Wright's   stain,   1  part.     With  this  solution   specimens  are  stained  for 


252 


LABORATORY   AIDS   IN   SURGICAL    DIAGNOSIS 


several  minutes,  quickly  washed  in  water,  and  dried  with  filter-paper.  Micro- 
scopic examination  of  the  slides  shows  the  character  of  the  red  corpuscles,  of 
nucleated  ones  if  any  are  present,  ])lasmodia,  etc.,  and  the  differential  count 
is  obtained  by  noting  the  relative  number  of  the  different  varieties  of  leukocytes, 
successively  encountered  by  moving  the  slide  with  a  mechanical  stage;  an 
actual  count  of  500  is  usually  sufficient. 

The  table  of  5000  examinations  mentioned  above  shows  a  normal  differ- 
ential count  of  leukocytes  to  be  as  follows : 


Leukocytes. 


Small  Lymphocytes 

Large  Lymphocytes 

Polynuclear  Neutrophiles . 

Eosinophiles 

Basophiles 


Percentages. 


Low. 


24.0 
3.0 

59.0 
0.2 

None 


High. 


35.0 

10.0 

68.0 

4.0 

0.4 


Average. 


28.0 
7.5 

62.0 
LO 
0.2 


Actual  Number  in 
1  c.MM.  Based  on 
Average  L  e  u  k  o - 
CYTE  Count  of  6700. 


1,876 

502 

4,154 

67 

7 


lodophilic  Reaction.  —  In  a  number  of  pathologic  conditions  the  pro- 
toplasm of  the  polynuclear  cells  has  an  affinity  for  iodin,  and  when  stained 


Fig.  53. — Thatcher  "Mosquito." 

with  the  reagent,  shows  an  intense  brown  coloring  with  granules  of  even  darker 
color,  while  the  specimen  without  this  affinity  shows  a  slight  yellow  color  only. 
The  value  of  the  reaction  will  be  considered  later. 

The  test  is  applied  as  follows:  A  drop  of  the  reagent  is  placed  on  the  dry 
and  unstained  blood  shde  and  a  cover-glass  applied.  The  specimen  is  examined 
under  the  microscope  after  a  lapse  of  about  three  minutes.  The  reagent  is 
easily  made  fresh  for  each  examination  by  mixing  1  part  of  Lugol's  solution 
with  2  parts  of  pure  glycerin. 

Cryoscopy  of  the  Blood.— The  value  of  this  procedure,  as  well  as  the 
technic  of  the  same,  will  be  detailed  under  the  head  of  Urine  Analysis. 

Blood=CUltures.— The  direct  search  for  bacteria  in  blood-smears  is 
very  rarely  successful,  and  may  be  disregarded  for  practical  purposes,  but  their 


EXAMINATION    OF   THE    BLOOD  253 


(Icinonstration  bv  cultuiv  from  the  blood  is  of  great  importance  especially  in  the 
matter  of  prognosis.     The  presence  of  streptococci  makes  the  prognosis  ex- 
ceecUno-ly  gra^^^  while  the  presence  of  staphylococci  is  much  more  frequently 
olTowe^d  b?  recovery.     Scrupulous  care  to  prevent  contamination  of  the  culture 
is  mperative,  and  many  misleading  results  may  be  ascnbedto  imperfect  asepsis 
ThXnd  of  the  elbow  must  be  rendered  thoroughly  aseptic  m  the  most  stringen 
manner  of  the  surgeon  ;    compression  of  the  arm  will  distend  the  superhcia 
veins  and  render  ^them  more  prominent.      The   hypodermic   needle  0^^^^ 
previously  sterilized  Thatcher  "mosquito,"  shown  m  Fig.  53,  is  now  thrust 
into    the    vessel    and    the   blood  immediately  flows  into  the  receptacle.     A 
previous  small  incision  reduces  to  a  minimum  the  hability  to  pick  up  organ- 
fsmsfrl  the  skin.     One  c.c.  of  blood  is  now  added  to  100--'^W    "l^toT 
fluid  culture-medium  in  a  suitable  flask,  mixed,  and  placed  m    he  incubator 
Three  such  flasks  are  usually  prepared.     Should  a  growth  develop,  the  exac 
character  of  the  organism  is  determined  by  transplantation  and  microscopic 
tm  na  ion,  as  detailed  in  the  section  on  Bacteriology.     The  original  use  o 
fltiid  culture-media  will  be  found   much  more   satisfactory  than  the  use  of 
solid  ones,  though  plates  made  at  once  often  give  good  service. 

CLINICAL  SIGNIFICANCE  OF  BLOOD-CHANGES 

In  the  foflowmg  enumeration  the  features  of  interest  to  the  surgeon  are  given 
special   attention,  and  topics  belonging  to  general   medicine  ^^^  considered 
onlv  if  they  are  of  value  in  surgical  diagnosis  and  prognosis      Two  tables, 
however,  are  appended  briefly  enumerating  the  changes  noted  m  blood  diseases. 
Anemia  and  its  Influence  on  Surgical  Prognosis.-In  view  of  the 
present  state  of  hematology  the  arbitrary  rule  largely  held,  that  no  surgical 
procedure  is  to  be  undertaken  when  the  percentage  of  hemoglobin  is  below  oO, 
is  in  need  of  amendment.     The  determination  of  the  amount  of  hemoglobin  m 
those  specimens  poor  in  coloring-matter  is  very  crude  at  best,  and  an  opimon 
concerning  the  prognosis  in  any  operation  in  a  case  of  severe  anemia  is  much 
better  if  based  on  the  complete  blood-picture,  than  if  the  necessarily  crude 
estimate  of  the  amount  of  hemoglobin  alone  is  considered.     The  chlorotic  giri 
with  30  per  cent  hemoglobin,  4^  miflion  red  corpuscles,  a  normal  leukocyte 
count  and  a  normal  differential  count,  is  certainly  in  a  much  better  condition 
to   wi'thstand   an   imperative  operation  than  one  having  secondary  anemia 
with  50  per  cent  hemoglobin,  but  only  2  million  red  corpuscles,  a  marked 
leukopenia,  and  a  high  relative  lymphocytosis.  ^..^.u^ 

Leul^ocytosis  and  Differential  Count  in  Inflammation.— This  is  to  the 
surcreon  the  most  important  feature  in  blood  examination,  and  consequently 
deserves  consideration  at  length.  For  a  long  time  the  number  of  leukocytes  in 
a  o-iven  quantity  of  blood  has  been  looked  to  as  a  guide  for  the  exist^ence  and 
severity  of  the  inflammatorv  process,  with  a  view  of  determmmg  the  degree  ot 
leukocytosis  which  shows  inflammation  without  exudate  or  with  serous 
noninfectious  exudate,  the  degree  with  which  a  purulent  exudate  may 
be  expected,  and,  finally,  that  which  indicates  a  degree  of  systemic  poison- 
ing that  would  make"  any  operative  interference  a  hazardous  Procedure. 
It  was  soon  found  that  arbitrary  limits  could  not  be  established,  and  that  the 
presence  of  leukocvtosis  was  not  invariable  in  suppurative  conditions,  partic- 
ularly in  the  fulniinating  cases.  This  latter  feature  has  been  the  greatest 
obstacle  to  progress,  as  it  has  discouraged  observation. 


254 


LABORATORY    AIDS    IN   SURGICAL    DIAGNOSIS 


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0 

C3 

0 

aj 

^ 

ft 

tH 

S 

0 

J2 

C3 

JG 

+3 

ft 

^ 

s 

ft 

>:  03 

;>io3 

0  aj 

Si 

-< 

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fee 


EXAMINATION    OF   THE    BLOOD 
APPROXIMATE  DIFFERENTIAL  COUNT  OF  LEUKOCYTES. 


255 


Leukocytes. 


►J  a 

00 

N 

<  0 

S  o 

0 

°3 

OPQ 

n 

«-< 

•z 

o 

m 

28% 

35% 

38% 

7% 

6% 

6% 

62% 

58% 

55% 

1% 

,      1% 

1% 

0.2% 

0.2% 

0.2% 

h  t;  - 

Q  <  ^ 

5  K  w 

^  0.  u; 


S  P 

^  H 

^.  H  a 

O  -^  «s 

K  K  W 

a  0-  w 


o  U) 

J::  1-1 


Small  lymphocytes 

Large  lymphocytes 

Polynuclear  neutrophiles . 

Eoshiophiles 

Basophiles   

Myelocytes 

Eosinophilic  myelocytes .  . 


42% 

4% 
50% 

3% 

0.2% 

1% 


4% 
90% 
4% 
0.5% 

2% 


88% 
5% 
7% 
0.2% 


8% 

3% 
30% 

6% 

0.2% 
45% 

8% 


Leukocytosis  is  largely  dependent  on  body  resistance  toward  infection,  and 
therefore  the  degree  of  increase  can  he  no  guide  to  the  intensity  of  the  'pathologic 
process.  Good  resistance  will  produce  pronounced  leukocytosis  even  in  slight 
infections,  and  poor  resistance  but  little  leukocytosis  in  slight  infections,  and 
possibly  none  at  all  in  grave  infections.  No  adequate  clinical  method  exists  by 
which  this  body  resistance  can  be  determined  with  sufficient  accuracy  to  apply 
it  as  a  factor  in  the  leukocyte  count,  and  this  is  the  key  to  the  disappointments 
encountered  by  the  surgeon  in  utilizing  these  counts  in  diagnosis.  It  is  also  the 
reason  why  arbitrary  leukocyte  count  standards  indicating  definite  degrees  of 
lesion  cannot  be  fixed.  At  first  a  leukocytosis  of  10,000  was  looked  upon  as 
indicating  the  presence  of  pus,  while  more  recently  it  has  been  stated  that  at 
least  35,000  leukocytes  must  be  present  before  pus  may  be  suspected,  though 
pus  is  often  present  with  much  lower  counts. 

It  has  been  found,  however,  that  the  quantitative  relation  or  differential 
count  of  leukocytes  offers  a  better  guide  to  the  status  of  an  inflammatory 
process  than  the  mere  presence  of  leukocytosis,  with  the  additional  advantage 
that  it  is  not  particularly  influenced  by  body  resistance.  Furthermore  the 
leukocytosis  present  with  a  given  differential  count  is  a  direct  indicator  of  body 
resistance.  The  particular  point  in  question  is  the  relative  percentage  of 
polynuclear  neutrophiles.  This  percentage  varies  somewhat  in  health,  as 
shown  in  the  above  table.  Moderate  fluctuations  in  the  anemia  accompany- 
ing most  pathologic  states  as  well  as  in  the  different  stages  of  body  resist- 
ance are  also  observed.  These  fluctuations,  however,  are  within  fairly  narrow 
limits.  A  careful  analysis  of  1415  blood  examinations  in  surgical  cases  shows 
three   distinct   blood   pictures   in   inflammatory  lesions,  grouped  as  follows: 

1. — A  relative  percentage  of  polynuclear  cells  below  70,  with  on  inflam- 
matory leukocytosis  of  any  degree,  excludes  the  presence  of  gangrene  or  pus,  at 
the  time  the  blood  examination  is'  made,  and  usually  indicates  good  body 
resistance  toward  infection.  Of  the  large  number  of  instances,  but  two  will  be 
briefly  mentioned,  which  will  illustrate  the  point. 

No.  12,971. — A  robust  young  woman.  Red  cells  4,900,000.  Hemoglobin 
82  per  cent.  Serous  otitis  media.  Owing  to  extreme  pain,  condition  of 
pulse,  etc.,  acute  mastoid  disease  suspected.  Leukocyte  count  28,400.  Poly- 
nuclear cells  59.7  per  cent.     Clinical  picture  and  leukocytosis  would  have 


256  LABORATORY   AIDS   IN    SURGICAL    DIAGNOSIS 

indicated  immediate  operation,  but  the  normal  polynuclear  percentage  led  the 
aurist  to  wait,  and  a  prompt  recovery  without  purulent  exudate  made  opera- 
tion unnecessary. 

No.  13,610. — A  boy,  convalescing  from  severe  attack  of  an  acute  infectious 
disease,  presented  a  clinical  picture  of  acute  appendicitis  and  a  leukocytosis 
of  25,100.  While  surgical  interference  seemed  urgently  indicated,  the  general 
condition  made  it  a  risk  not  to  be  incurred  unless  imperative.  The  polynuclear 
percentage  of  63.5  induced  the  attending  physician  to  wait,  and  while  he  spent 
anxious  da^^s  in  which  the  clinical  signs  and  blood  picture  remained  stationar}-, 
resolution  without  pus  or  gangrene  resulted,  and  the  child  was  saved  an  opera- 
tion at  a  time  when  he  was  in  very  poor  condition  to  stand  it. 

2. — An  increased  relative  percentage  of  polynuclear  cells,  even  with 
little  or  no  inflammatory  leukocytosis,  is  still  an  absolute  indication  of  the 
inflammatory  process,  and  the  percentage  is  a  direct  guide  to  the  severity  of  the 
infection.  As  above  stated,  in  all  the  cases  no  pus  or  gangrene  was  ever 
observed  with  a  polynuclear  percentage  below  70.  In  children,  in  whom  the 
polynuclear  percentage  is  norjnally  lower  than  in  adults,  pus  or  gangrene  has 
been  observed  with  the  percentage  as  low  as  73.  In  adults  a  purulent  exudate 
or  a  gangrenous  process  is  decidedly  uncommon  with  less  than  80  per  cent  of 
polynuclear  cells,  and  the  probability  of  their  presence  increases  with  the 
percentage.  Eighty-five  per  cent  or  over  of  polynuclear  cells  was  never  seen 
without  a  purulent  exudate  or  gangrenous  process  irrespective  of  the  leukocyte 
count.  Ninety  per  cent  of  polynuclear  cells  has  always  indicated  a  very 
severe  degree  of  cachexia,  if  the  term  may  be  used,  and  while  one  specimen 
of  95.2  per  cent  was  seen  where  recovery  followed  operation,  all  other  cases  in 
which  the  percentage  was  over  94.5  resulted  fatally.  It  is  not  wise  to  estab- 
lish narrow  arbitrary  limits,  nor  should  this  be  attempted,  but  the  above 
figures  are  based  on  the  1400  surgical  cases  studied  in  this  way. 

This  second  type  of  increased  polynuclear  percentage  is  the  most  inter- 
esting one,  as  it  particularly  demonstrates  the  value  of  the  advocated  pro- 
cedure in  cases  that  are  usually  in  urgent  need  of  operation  on  account  of 
poor  body  resistance.     The  few  cited  cases  will  illustrate: 

No.  11,509. — A  young  woman  in  apparently  good  condition.  Red  cells 
4,208,000.  Hemoglobin  72  per  cent.  Severe  pelvic  cellulitis  from  strep- 
tococcus infection,  and  somewhat  vague  manifestations  of  an  abscess,  with  a 
leukocyte  count  of  7200.  Her  serious  condition  could  be  explained  clinically 
by  the  intensity  of  the  inflammatory  process,  but  the  polynuclear  percentage 
of  87  indicated  the  necessity  for  immediate  operation,  which  revealed  a  large 
collection  of  pus.     The  operation  was  followed  bv  recovery. 

No.  12,331.— A  rather  feeble  elderly  lady.  Red  cefls  4,400,000.  Hem- 
oglobin 70  per  cent  "^dth  typic  clinical  evidences  of  appendicitis.  The  attend- 
ing physician  and  the  consulting  surgeon  advocated  operation,  but  the  con- 
sulting physician  advised  waiting.  Leukocytes  13.200.  Polynuclear  cells 
82.4  per  cent.  '  Owing  to  the  latter  feature,  the  surgeon  insisted  on  operating, 
and  found  a  perforated  gangrenous  appendix  and  spreading  general  peri- 
tonitis. 

No.  13,702. — A  young  man  apparently  in  good  condition.  Red  cells 
4,820,000.  Hemoglobin  80  per  cent;  patient  convalescing  from  an  operation 
for  purulent  otitis  media  and  mastoid  involvement,  began  to  have  evidences 
of  meningeal  irritation,  with  but  slight  clinical  manifestations  of  acute  inflam- 


.,ao>I   ,A 


))i9iq 


Typic  Blood  Pictures  in 

A.  Normal  blood.     1.   Small  lymphocyte. 

2.  Large  lymphocyte.     3.  Polynuclear  neu- 

trophile.    4.  Eosinophile.    5    Basophile.    Red 

corpuscles  all  normal. 

C.  Inflammatory  leukocytosis  with  in- 
crease in  polynuclear  cells.  Note  large 
number  of  polynuclear  neutrophiles. 

E.  Chronic  lymphatic  leukemia.  Note 
predominance  of  small  lymphocytes. 


THE  Following  Conditions  : 

B.  Abnormal  cellular  elements  found  in 
blood.  1.  Poikilocytes,  microcytes  and  ma- 
crocytes.  2.  Normoblasts.  3.  Megaloblasts. 
4.   Myelocytes.     5.  Eosinophilic  myelocytes. 

D.  Acute  lymphatic  leukemia.  Note  pre- 
dominance of  large  lymphocytes  which  stain 
rather  poorly. 

F.  Myelogenous  leukemia.  Note  myelo- 
cytes and  many  nucleated  red  cells. 


PLATE  111 


EXAMIXATIOX    OF    THE    BLOOD  257 

mation.  Leukocyte  count  11,900.  Polynuclear  cells  82.3  per  cent.  Im- 
mediate operation  revealed  large  abscess,  and  patient  subsecjuently  died  of 
meningitis. 

3. — An  increased  relative  percentage  of  polynuclear  cells  with  a  decided 
inflammatory  leukocytosis.  Most  of  the  cases  of  inflammatory  lesions,  with 
or  without  purulent  exudate,  meet  the  specifications  of  this  class.  Here,  as 
in  the  last  series,  the  percentage  of  polynuclear  cells  was  found  to  be  an 
accurate  guide  to  the  status  of  the  inflammatory  lesion.  The  figures  ciuoted 
above  apply  here  as  well. 

The  body  resistance  toward  the  infection  is  a  most  miportant  point,  and 
the  clinical  manifestations  are  usually  a  good  guide,  but  by  no  means  an 
invariable  one.  Good  resistance,  marked  leukocytosis;  poor  resistance,  little  or 
no  leukocytosis,  is  the  old  rule.  As  stated  above,  the  leukocytosis  with  a  given 
percentage  of  polynuclear  cells  is  one  of  the  best  indicators  of  this  body  re- 
sistance, when  we  accept  the  theory  that  the  polynuclear  percentage  is  the  index 
of  the  degree  of  the  inflammatory  lesion. 

For  example,  a  patient  has  an  inflammatory  lesion  without  purulent  exu- 
date, and  a  polynuclear  percentage  of  75.  If  his  leukocyte  count  is  25,000,  the 
body  resistance  is  much  better  than  if  the  count  is  10,000.  Another  case  has 
an  acute  inflammation  with  abscess,  and  a  polynuclear  percentage  of  84.  If 
the  leukocyte  count  is  30,000  the  body  resistance  is  much  better  than  if  the 
count  is  15,000.  The  severely  toxic  patient  with  92  per  cent  polynuclear  cells 
is  combating  his  disease  with  greater  energy  and  success  if  he  has  40,000  leu- 
kocytes in  1  c.mm.  than  if  they  are  only  20,000;  and  should  the  leukocyte 
count  be  7000,  this  is  a  clear  indication  of  an  absence  of  all  systemic  effort  to 
overcome  the  infection. 

The  following  must  be  kept  in  mind:  Few  rules  ever  existed  that  have  no 
exceptions.  Inflammatory  lesions  belonging  to  the  domain  of  general  medicine, 
notaUij  pneumonia,  and  severely  toxic  conditions  such  as  scarlet  fever  show  blood 
pictures  which  closely  simulate  those  of  surgical  suppurative  lesions. 

lodophilia. — This  reaction,  the  technic  for  obtaining  which  has  been 
detailed,  is  noted  in  the  blood  in  all  inflammatory  lesions,  and  its  presence  as 
well  as  its  intensity  has  been  used  as  a  guide  to  the  character  and  severity  of 
the  inflammatory  process.  Personal  experience  teaches  its  inferiority  as  a 
guide  to  the  degree  and  type  of  the  inflammatory  process  as  compared  with 
the  method  detailed  above.  A  distinct  iodophihc  reaction  is  always  obtained 
in  a  pronounced  leukocytosis,  and  may  erroneously  indicate  a  suppurative 
process,  which  error  would  be  most  likely  in  the  class  of  cases  enumerated 
in  Group  1. 

Tuberculosis. — Lesions  due  to  pure  tuberculous  infections,  necrotic  or 
otherwise,  do  not  occasion  a  leukocytosis  or  change  in  the  differential  count,  the 
blood  usually  presenting  a  picture  of  secondary  anemia.  If  the  tuberculous 
lesions  are  the  seat  of  a  mixed  infection,  the  leukocytosis  and  differential 
count  behave  as  they  would  if  the  additional  microorganisms  were  present 
alone.  It  is  often  observed  that  tuberculous  meningitis  and  tuberculous 
peritonitis  seen  in  children  present  a  leukocytosis  and  polynuclear  increase, 
but  the  presence  of  a  mixed  infection  to  account  for  this  is  by  no  means 
excluded,  though  not  invariable"  found  on  examination. 
18 


258  LABORATORY    AIDS    IN    SURGICAL    DIAGNOSIS 

Malignant  Disease. — It  was  hoped  that  the  examination  of  the  blood 
would  present  characteristics  of  pathognomonic  value  in  the  diagnosis  of  malig- 
nant disease,  but  up  to  the  present  this  hope  has  not  been  realized. 

Carcinoma  is  usually  accompanied  by  the  evidences  of  a  rather  pronounced 
secondary  anemia,  and  oftentimes  on  differential  count,  shows  a  leukocytosis 
and  an  increase  in  the  percentage  of  polynuclear  cells,  which  in  the  absence  of 
a  febrile  movement  is  supposed  to  be  of  value  in  the  diagnosis.  When  these 
features  are  found,  they  may  be  significant,  but  many  cases  of  carcinoma  fail 
to  show  them.  It  is  believed  that  the  leukocytosis  and  pohmuclear  increase 
observed  in  these  cases  are  due  to  a  secondary  infection,  and  thus  may  be  a 
guide  to  the  extent  of  the  accompanying  inflammation,  but  that  they  are  no 
indication  of  the  nature  or  severity  of  the  primary  lesion. 

Sarcoma  is  usviaUy  accompanied  by  a  secondary  anemia  also  noted  in 
carcinoma,  and  more  frequently,  but  not  invariably,  shows  a  decided  leu- 
kocytosis and  polynuclear  increase.  The  value  and  significance  of  these 
changes  are  believed  to  be  the  same  as  in  cancer. 

In  the  differential  diagnosis  of  gastric  ulcer  and  gastric  cancer  the 
blood  examination  usually  lends  no  conclusive  evidence,  but  it  is  noteworthy 
that  in  ulcer  a  leukocytosis  is  rare,  the  secondary  anemia  seldom  pronounced^ 
and  a  relative  lymphocytosis  common.  In  the  differential  diagnosis  of  obscure 
malignant  disease  and  pernicious  anemia,  the  following  features  are  worthy 
of  note,  viz.: 

Pernicious  Anemia.  Carcinoma. 

Loss  of  red  corpuscles  greater  than  that  of  Loss  of  hemoglobin  and  red  cells  approxi- 

hemoglobin  (low  color  index).  mately  equal,  as  in  all  secondary  anemia. 

In  number  of  nucleated  red  cells,  megalo-  If  nucleated  red  cells  are  present,  they  are 

blasts  always  predominate.  only  normoblasts. 

Leukopenia  common  and  differential  count  Leukocytosis  common,  and  if  present  shows 

shows  relative  lymphocytosis.  an  increase  in  polynuclear  percentage. 

Scurvy  and  allied  conditions  and  pronounced  jaundice  are  frequently 
associated  with  a  marked  reduction  in  the  coagulability  of  the  blood,  which 
feature  is  of  importance  in  contemplated  surgical  procedure.  Determining 
the  coagulation  period  is  a  rather  tedious  matter,  and  but  little  work  in  this 
direction  has  yet  been  done.  The  coagulometer  of  Wright  is  the  best  appa- 
ratus devised  for  the  purpose. 

Acute  Lymphatic  Leukemia. — The  general  blood-picture  in  this  disease 
has  been  outlined  in  the  tables  on  preceding  pages.  In  these  cases  a  sudden 
increase  in  lymphatic  tissue,  interorganic  hemorrhages,  or  both,  with  tem- 
perature and  other  clinical  evidences,  often  closely  simulate  acute  inflammatory 
lesions,  and  therefore  are  brought  to  the  attention  of  the  surgeon.  Omission 
of  a  diagnosis  by  proper  examination  of  the  blood  may  lead  to  operative  inter- 
ference for  a  supposed  abscess,  which  can  but  hasten  the  invariably  fatal  out- 
come of  this  disease.  While  the  leukocytosis  encountered  is  usually  much 
higher  than  that  of  inflammation,  this  may  not  be  so,  and  a  differential  count 
is  an  absolute  necessity  in  establishing  the  diagnosis. 

Chronic  Myelogenous  and  Chronic  Lymphatic  Leukemia.— The  gen- 
eral blood-picture  in  these  conditions  has  been  detailed  in  the  tables.  The 
only  interest  that  they  have  for  the  surgeon  is  in  the  diagnosis  of  enlargements, 
glandular  and  otherwise,  encountered  in  the  body.     Concerning  the  significance 


URINE    ANALYSIS  259 

of  these  diseases  in  surgical  jtrognosis  but  little  has  been  written,  ])robably 
because  operations  are  rarely  undertaken.  Personal  observation  of  the  writer 
is  limited  to  parturition  in  two  cases  of  the  myelogenous  form.  Both  had  nor- 
mal confinements,  one  a  brisk  but  short  postpartum  hemorrhage.  A  moderate 
febrile  movement  was  noted  in  both  during  the  postpartum  period  of  several 
weeks,  without  sepsis  or  change  in  the  blood-picture.  The  parturition  did  not 
seem  to  alter  the  general  condition.  As  the  diagnosis  in  both  was  not  made 
until  the  time  of  parturition,  no  data  are  at  hand  as  to  the  duration  of  the 
disease  or  the  influence  of  the  pregnancy  on  it.  Both  children  were  well 
nourished  and  perfectly  normal. 

Hodgkin's  disease  or  pseudoleukemia  is  of  interest  here  on  account  of 
the  differential  diagnosis  from  13'mphatic  leukemia;  the  details  of  the 
blood-pictures  have  been  enumerated.  The  differential  diagnosis  of  pseudo- 
leukemia and  lymphosarcoma  is  often  difficult,  but  the  latter  is  likely  to 
show  a  greater  degree  of  secondary  anemia,  less  relative  lymphocytosis,  and 
frequently  a  leukocytosis  with  polynuclear  increase. 

BIood=pressure. — The  determination  of  the  blood-pressure  by  means  of 
the  Riva-Rocci  or  similar  apparatus  has  been  found  to  be  of  considerable 
value,  but  it  is  a  clinical  rather  than  a  laboratory  procedure. 

URINE  ANALYSIS 

In  consequence  of  the  increased  value  of  this  procedure  during  late  j^ears, 
its  technic  has  undergone  change  and  improvement.  At  one  time  the  clinician 
believed  that,  when  he  had  found  the  specific  gravity,  had  tested  the  urine 
for  albumin  and  sugar,  and  had  made  a  hasty  microscopic  examination  of 
the  sediment,  he  had  exhausted  all  practical  information  to  be  obtained  from 
this  complex  fluid.  Today  an  examination  of  this  kind  is  not  considered 
sufficiently  exhaustive  to  meet  the  exacting  demands  of  the  expert  diagnos- 
tician. 

The  general  idea  formerly  held,  that  the  presence  of  albumin  indicates  a 
nephritis,  and  that  the  finding  of  granular  casts  means  the  presence  of  chronic 
renal  disease,  must  be  alDandoned.  Albumin  may  be  found  in  the  urine  without 
a  true  nephritis,  and,  on  the  other  hand,  a  nephritis  does  not  necessarily  mean 
that  albumin  is  constantly  present.  The  same  applies  to  the  presence  of  casts; 
many  granular  casts  may  occur  in  convalescing  acute  nephritis  and  perfect 
recovery  result,  and,  on  the  other  hand,  cases  of  advanced  but  ciuiescent 
chronic  nephritis  may  show  no  casts  for  long  or  short  periods. 

In  the  following  consideration  of  the  subject  the  clinical  significance  of  the 
latter  to  the  surgeon  is  kept  constantly  in  mind ;  the  portion  belonging  to 
general  medicine  is  alluded  to  when  it  seems  necessary,  and  the  technic  is 
elaborated  only  where  experience  teaches  its  advisability. 

The  cardinal  points  in  urine  analysis  are  the  selection  of  a  proper  specimen 
and  a  methodic  routine  anah'sis.  In  most  instances  a  twenty-four  hour  speci- 
men should  be  insisted  on,  as  it  presents  many  significant  points  not  learned 
in  any  other  way,  and  careful  instructions  to  begin  and  end  the  period  of 
twentv-four  hours  with  an  empty  bladder  and  to  prevent  loss  at  stool  are 
usualh'  necessary.  If  methodic  routine  analysis  is  not  constant,  important 
unsuspected  conditions  may  be  overlooked ;  for  example,  owing  to  the  omission 


260  LABORATORY   AIDS   IX    SURGICAL    DIAGNOSIS 

of  a  test  for  glucose  because  the  specific  gravity  created  no  susjjiciou  in  this 
direction,  a  case  of  postoperative  cUabetic  coma  may  be  a  disagreeable  surprise. 
Before  considering  the  typic  and  atypic  pictures  presented  by  the  urine 
in  the  more  important  surgical  diseases,  there  are  a  few  general  considera- 
tions which  merit  comment. 

THE  QUANTITY  OF  URINE 

The  normal  cjuantity  of  urine  is,  generally  speaking,  from  1000  c.c.  to  1200 
c.c,  though  persons  in  perfect  health  regular!}'  pass  smaller  or  larger  amounts, 
owdng  to  the  fact  that  they  habitually  take  smaller  or  larger  amounts  of  fluid 
during  the  clay. 

Polyuria,  or  an  increased  daily  amount  of  urine,  may  be  due  to  phy,siologic 
or  pathologic  causes.  Aside  from  the  common  pathologic  causes,  diabetes 
mellitus,  so-called  diabetes  insipidus,  neurotic  diseases,  that  following  acute  feb- 
rile diseases,  chronic  nephritis  of  atrophic  type,  and  other  conditions  belonging 
to  general  medicine,  the  causes  which  particularly  interest  the  surgeon  in 
diagnosis  are  (1)  the  polyuria  clue  to  diuretics  and  the  ordered  intake  of  much 
fluid;  (2)  pyelitis  from  any  cause;  (3)  a  previously  removed  kidney;  (4) 
compensatory  polyuria  due  to  occlusion  of  one  ureter;  (5)  the  polyuria  seen 
with  myelomas  of  bone  and  an  excretion  of  Bence-Jones  albumin .  Oliguria, 
or  the  diminished  excretion  of  urine,  is  noted  in  febrile  diseases,  cardiac  insuf- 
ficiency, acute  nephritis,  and  in  many  other  conditions  which  belong  to  the 
domain  of  general  medicine.  The  causes  which  interest  the  surgeon  are  (1) 
the  post-operative  oliguria,  especially  if  hemorrhage  has  been  profuse;  (2) 
the  oliguria  noted  immediately  after  the  removal  of  one  kidney,  which  is  soon 
followed  by  a  polyuria;  (3)  the  fact  that  a  unilateral  painful  lesion  in  or 
about  the  kidney,  without  obstruction  to  the  flow  of  urine,  may  produce  a 
decided  reflex  oliguria.  This  should  be  noted  particularly.  Anuria,  or  the 
absence  of  renal  excretion,  is  an  exaggerated  form  of  oliguria,  and  is  due  to 
the  same  causes. 

ALBUMIN 

In  testing  for  albumin  the  methods  selected  should  be  such  that  not  only 
serum-albumin  but  also  nucleo-albumin,  albumose,  and  Bence-Jones  albumin 
are  revealed  at  the  same  time.  Absolute  accuracy  in  this  regard  calls  for  the 
use  of  many  tests  not  feasible  as  a  surgeon's  routine  procedure,  but  for  general 
clinical  routine  work  the  use  of  two  tests  is  advised — the  heat  and  nitric  acid 
test  and  the  nitric-magnesium  test. 

The  heat  and  nitric  acid  test  should  be  made  as  follows:  A  test-tube 
three-quarters  full  of  perfectly  clear  filtered  urine  is  inclined  at  an  angle  of 
45  degrees,  and  the  upper  inch  heated  by  means  of  a  Bunsen  burner  or  an 
alcohol  lamp.  A  turbidity  which  develops  on  heating  and  continues  to  increase 
may  be  due  to  phosphates,  serum-albumin,  Bence-Jones  albumin,  nucleo- 
albumin,  or  albumose.  If  this  turbidity  disappears  in  a  large  measure  or 
altogether  when  the  boiling-point  is  reached,  albumose  or  Bence-Jones 
albumin  is  present.  When  the  specimen  is  boihng,  a  few  drops  of  nitric  acid 
are  added,  which  will  dissolve  the  phosphates  and  increa.se  the  turbidity  due 
to  serum-albumin.     Comparison  with  the  lower  part  of  the  test-tube  containing 


URINE   ANALYSIS 


261 


\hv  uriiu'  whicli  has  not  been  heated  will  show  faint  traces,  especially  if  a  black 
screen  is  held  between  the  test-tube  and  the  light .  ( )n  cooling,  the  turbidity  due 
to  nuu'in,  albumose,  or  Bence-Jones  albumin  recurs.  If  a  reaction  other 
than  that  for  serum-albumin  has  been  obtained,  it  must  be  corroborated  Ijy 
specific  tests.* 

The  nitric-magnesium  test  is  a  cold  test,  made  by  contact  of  the  urine  with 
the  reagent.  This  may  be  made  in  any  one  of  the  many  ways  taught  in  the 
laboratory,  but  the  albuminometer  shown  in  the  accompanying  cut  (Fig.  54) 
is  a  handy  instrument  for  this  test  and  can  also  be  used  for  the  numerous 
other  contact  tests  made  by  the  clinician.  The  clear  glass  instrument  is  pref- 
erable to  one  with  a  black  and  a  white  background  painted  on  it.  The  clear 
filtered  mine  is  poured  into  the  large  tube  until  this  is  about  half  full.  The 
reagent  is  poured  into  the  small  funnel-end  tube  until  this  is  not  cjuite  full. 
The  latter  makes  its  w^ay  beneath  the  former  and 
a  clean  line  of  contact  results.  Serum-albumin 
shows  a  turbidity  at  the  junction  of  the  urine  and 
reagent .  Mucin  or  albumose  shows  an  opalescent,  not 
clearly  defined  turbidity  above  the  junction,  in  the 
urine.  These  reactions  are  more  clearly  seen  by 
placing  any  black  object  behind  the  instrument. 

The  nitric-magnesium  reagent  is  made  as  follows : 

Saturated  aqueous  solution  magnesium  sulfate.  .100  c.c. 
Nitric  acid 20  c.c. 

The  quantitative  determination  of  albumin 

if  absolute  accuracy  is  essential,  is  a  rather  tedious 
laboratory  procedure.  For  clinical  purposes,  however, 
this  is  rarely  necessary,  and  the  results  obtained  by 
use  of  the  E  s  b  a  c  h  albuminometer  (Fig.  55)  meet 
most  of  the  requirements.  The  method  is  very 
simple,  and  is  briefly  as  follows :  The  tube,  as  shown 
in  the  illustration,  is  filled  to  the  mark  U  with 
filtered  urine,  acidulated  if  necessary  with  acetic 
acid,  and  then  filled  to  the  mark  R  with  reagent. 
It   is  closed  with  a  rubber  stopper,  inverted  twelve 

times,  and  set  aside  in  a  cool  place  for  twenty-four  hours  in  a  vertical 
position.  The  amount  of  albumin  is  read  from  the  scale,  which  indicates 
grams  per  liter,  or  parts  per  thousand  by  weight.  The  specific  gravity  of  the 
urine  should  be  not  higher  than  1010,  and  the  amount  of  albumin  present 
should  not  exceed  4  per  mille  (parts  per  thousand)  by  weight — if  it  exceeds 
this  the  specimen  should  be  diluted  with  water.  It  is  a  good  plan  to  make 
a  preliminary  examination  in  an  ordinary  test-tu]_^e  to  estimate  approximately 
the  amount  of  all^umin  and  exclude  the  presence  of  a  considerable  amount 
of  albumose  which  is  redissolved  by  heating  the  mixture.  If  considerable 
albumose  is  present,  the  method  should  not  be  used. 
Esbach's  reagent  is  made  as  follows: 

Picric  acid  (c.  p.) 5  grams 

Citric   acid 10  grams 

Dissolved  in  distilled  water  500  c.c.  and  filtered. 

*  For  a  detailed  description  of  these  tests  the  reader  is  referred  to  Simon's  "Clinical 
Diagnosis,"  5th  edition,  1904,  or  to  some  other  good  work  on  clinical  chemistry. 


Fig.  54. — Albuminometer. 


262 


LABORATORY   AIDS   IN   SURGICAL    DIAGNOSIS 


GLUCOSE  AND  ALLIED  SUBSTANCES 

In  routine  work  these  substances  are  likely  to  be  recorded  simply  as  sugar, 
whereas  one  or  another  of  the  usual  tests  for  glucose  also  responds  to  other 
substances.  This  matter  is  of  interest  to  the  surgeon,  as  the  presence  of  glu- 
cose in  the  urine  is  often  the  first  sign  he  has  of  the  existence  of  a  complicating 
true  diabetes.  Gh^curonic  acid  and  pentose  are  chiefly  of  interest,  as  these  also 
respond  to  the  copper  test,  and  may  mean  only  a  slightly  disturbed  body 
metabolism. 

In  testing  for  sugar  in  a  routine  way,  two  methods  should  be  used,  the  cop- 
per test  and  the  bismuth  test.  Fehling's  solution  is  the  copper  test  com- 
monly employed,  but  it  is  objectionable  because  it  must  be  kept  in  two  solu- 
tions and  needs  mixing  up  for  use,  whereas  Haines's  solution  is  an 
equally  sensitive  test,  needs  no  dilution,  and  keeps  for  a  long 
time. 

Haines's  test  is   made  as   follows:   A   few    drops  of   urine 
are  added  to  a  dram  of  reagent  and  boiled.     If  sugar  is  pres- 
ent the  characteristic  copper  reduction  takes  place. 
Haines's  solution  is  made  as  follows: 

Cupric  sulfate  (c.  p.) 3.0 

Glycerin,  pure 23.0 

Distilled  water 250.0 

Dissolve  and  add  potassium  hydrate,  pure 11.0 

The  bismuth  test  needs  no  comment.  Both  tests  are  made 
more  sensitive  by  placing  the  tubes  in  a  water-bath  after  simple 
boiling  shows  no  reaction. 

The  quantitative  estimation  of  glucose  is  usually  made 
by  means  of   the  fermentation   test    or    Fehling's  test.     The 
objection  to  the  former  is  the  time  required,  and  to  the  latter 
the  indefinite  end-reaction.     The  Rudisch  quantitative  test  is 
-7|«      recommended  on  account  of  its  simplicity  and  accuracy :  1  c.c. 
'5  |B      of  urine  measured  with  a  volumetric  pipet  is  placed  in  a  500  c.c. 
-4  IB       Erlenmayer  flask  and  100  c.c.  of  distilled    water   are    added. 
-3fB       j}-^ig  jg  placed  on  a  tripod  with  a  white  background,  and  heated. 
On  boiling,  the  reagent  is  added  in  small  amounts  from  an  ordi- 
nary or  a  Bincks  buret,  until  the  faint  blue  color  does  not  dis- 
appear  on   two  minutes'   boiling.      Each  cubic   centimeter  of 
reagent  used  equals  0.0011  gram  of  sugar  in  1  c.c.  urine.     The 
result  multiplied    by  100  gives  the  percentage,   or  the    result 
Fig.  5.5.— Es-       multiplied  by  the  number  of  cubic  centimeters  of  urine  voided 
MmoMETlH.      in  twenty-four  hours   gives   the   amount  in   grams  of   glucose 
excreted  in  twenty-four  hours. 
Example:  3000  c.c.  urine  voided  in  twenty-four  hours. 
Test  shows  use  of  23.2  c.c  reagent. 

23.2  X  0.0011  =  0.02552  gram  glucose  in  1  c.c.  X  100  =2.552%. 
0.02552  gram  glucose  in  1  c.c.  X  3000  c.c  voided  =76.56   grams   glucose 
excreted  in  twenty-four  hours. 

The  volumetric  sugar  test  solution  is  made  as  follows: 

Cupric  sulfate  crj^st 4.78  grams 

Sodium   sulfite  cryst 50.0    grams 

Sodium  carbonate  cryst 80.0    grams 

Ammonia  water  (10%),  to  make 500       c.c. 


URINE   ANALYSIS  263 

In  order  to  exclude  glycuronic  acid  or  licntose,  which  would  also  respond  to 
the  above  tests,  a  fermentation  test  is  made.  If  this  is  positive,  glucose  is 
present;  if  it  is  negative  and  the  copper  and  bismuth  tests  were  positive, 
glycvu'onic  acid  or  pentose  is  present.  For  corroborative  tests  for  these  sub- 
stances the  reader  is  referred  to  special  works. 

UREA 

While  the  value  of  the  knowledge  of  the  daily  excretion  of  urea  has  been  the 
subject  of  much  discussion,  it  is  certainly  true  that  a  ciuantitative  test  for  urea 
made  on  a  single  specimen  passed  at  any  time  of  day  is  an  absolutely  useless 
procedure.  The  really  absurd  record  of  grains  of  urea  per  ounce  must  be 
replaced  by  a  statement  of  grams  excreted  in  twenty-four  hours,  and  even  then 
the  clinical  value  is  not  nearly  so  great  as  we  formerly  supposed.  The  text- 
book statement  that  a  healthy  male  excretes  from  25  to  40  grams  of  urea  in 
twenty-four  hours  is  also  wrong.  From  16  to  28  grams  are  much  more  correct 
figures,  and  from  the  surgeon's  point  of  view  an  average  of  16  grams  should 
be  considered  the  normal  minimum. 

CHLORIDS 

In  the  efforts  to  determine  renal  functional  ability  by  the  new  methods 
devised  for  this  purpose  the  quantitative  estimation  of  the  chlorids  in  the  urine 
has  assumed  new  importance.  In  this  connection  it  is  well  to  state  that  the 
method  by  direct  titration  with  decinormal  solution  of  AgNOg  is  very  faulty, 
and,  in  order  to  secure  results  which  merit  any  consideration,  the  method  by 
incineration  or  other  more  accurate  procedure  must  be  used. 

MICROSCOPIC  EXAMINATION  OF  URINE 

The  great  value  of  the  centrifuge  for  precipitation  of  the  sediment,  aside 
from  its  time-saving  advantage,  is  established.  While  it  w^ould  be  folly  to 
belittle  the  information  gained  from  the  character  of  the  epithelial  cells 
in  a  urinary  sediment,  too  zealous  effort  to  establish  the  origin  of  individual 
cells  or  groups  of  the  same  must  be  discouraged,  and  the  opinion  as  to  the 
character  and  seat  of  a  lesion  is  better  if  based  on  the  many  characteristic 
general,  chemic,  and  microscopic  features  presented  by  the  specimen. 

FUNCTIONAL  DIAGNOSIS 

This  name  has  been  given  to  a  variety  of  procedures  the  aim  of  which  is  to 

determine  whether  the  kidneys  are  doing  normal  excretory  work.     j\Iuch  of 

what  has  been  advocated  has  proved  decidedly  useful,  though  not  infallible. 

The  most   important    procedures   advocated   at   present   are   the  following: 

Cryoscopy    of    the    blood,    to    determine    molecular    concentration. 

Cryoscopy  of  the  urine  for  the  same  purpose. 

Inducing  artificial  glycosuria,  separate  collection  of  urine  from  each 

kidney,  and  examination. 
Ingestion  of  anilin  dyes  for  the  same  purpose. 

Thorough  analysis  of  twenty-four  hour  specimen  of  urine,  preferably 
repeated. 


264  LABORATOKY  AIDS   IN    SURGICAL    DIAGNOSIS 

Cryoscopy  of  the  Blood,  to  determine  its  molecular  concentration,  is 
accomplished  by  learning  the  depression  of  its  freezing-point  as  com])ar('d 
with  that  of  distilled  water.  The  normal  molecular  concentration  of  the  blood 
causes  it  to  freeze  at  minus  0.56°  C,  the  freezing-point  of  distilled  water  being 
zero.  In  renal  insufficiency  the  solids  which  should  normally  be  excreted  are 
retained  in  the  circulating  blood  in  abnormal  amount,  increasing  its  molecular 
concentration  and  thus  lowering  its  freezing-point.  This  procedure  is  of  very 
decided  value  to  the  surgeon  as  an  aid  in  diagnosis  and  prognosis,  and  merits 
the  consideration  on  this  side  of  the  Atlantic  that  it  enjoys  in  continental 
Europe.  It  is  an  important  factor  in  the  prognosis  when  a  diseased  kidney 
is  to  be  removed ;  it  lends  much  weight  in  deciding  whether  a  kidney  should  be 
removed  or  not ;  it  forms  an  important  element  in  the  prognosis  after  one  kidney 
has  been  removed,  and  it  is  of  decided  value  in  estimating  the  functional  ability 
in  bilateral  kidney  disease,  thus  influencing  the  prognosis  of  any  operative 
procedure  on  persons  thus  afflicted.  A  normal  freezing-point  of  the  blood 
indicates  normal  renal  excretory  ability;  if  one  kidney  is  diseased  or  destroyed, 
the  other  is  doing  the  compensatory  work.  A  reduction  in  the  freezing-point 
to  minus  0.58°  C.  or  minus  0.61°  C.  indicates  that  both  kidneys  are  unable  to 
excrete  sohds  properly.  These  data  should  be  corroborated  by  all  available 
methods,  just  as  in  other  diagnostic  and  prognostic  investigation. 

Cryoscopy  of  the  Urine,  to  determine  the  molecular  concentration  of 
the  twenty-four  hour  specimen,  was  at  one  time  advocated  as  an  additional 
guide  in  estimating  functional  renal  ability,  but  experience  teaches  that  the 
wide  variations  met  in  health  and  disease  without  renal  insufficiency  (minus  0.9° 
C.  to  minus  2.0°  C.)  make  a  trustworthy  conclusion  based  on  this  procedure  a 
difficult  and  scarcely  feasible  matter.  This  test,  applied  to  specimens  of  urine 
separately  collected  from  each  kidney,  furnishes  much  more  satisfactory 
results  that  are  of  great  help  in  determining  which  is  the  diseased  kidney,  and 
in  estimating  the  degree  of  its  functional  impairment.  The  decreased  molecular 
concentration  noted  in  the  specimen  obtained  from  the  diseased  kidney  is 
often  much  more  marked  than  the  decreased  specific  gravity  and  the  lowered 
relative  amount  of  urea  and  chlorids  would  lead  one  to  believe.  The  ordered 
intake  of  an  unusual  amount  of  fluid  before  ureter  catheterization  makes  the 
procedure  less  tedious  to  both  surgeon  and  patient,  but  it  jeopardizes  the  value 
of  the  subseciuent  analysis  and  absolutely  destroys  the  significance  of  cryoscopy 
of  these  specimens,  as  the  healthy  kidney  may  excrete  water  more  rapidly 
than  the  cUseased  one,  though  the  latter  is  comparatively  impervious  to  solids. 
Even  the  polyuria  of  neurotic  persons,  under  the  circumstances,  should  be 
inhibited  as  far  as  possible  by  a  sedative  or  narcotic.  (The  technic  of  crvos- 
copy  is  detailed  below.) 

Inducing  Artificial  Qlucosuria. — The  method  of  inducing  artificial  glu- 
cosuria,  separately  collecting  urine,  and  determining  the  percentage  of  sugar 
excreted  by  each  kidney  is  also  used  as  a  guide  to  functional  ability.  Phlorid- 
zin,  0.005  gram,  is  given  by  hypodermic  injection  before  ureter-catheterization. 
This  method  never  gained  popularity  in  America  and  no  longer  enjoys  universal 
support  abroad.  Requiring  the  patient  to  ingest  methylene-blue  or  other 
anilin  dyes,  and  observing  the  time  intervening  before  the  color  appears  in  the 
urine,  as  well  as  the  intensity  of  the  color,  or  separately  collecting  the  urine 
from  each  kidney  and  afterward  comparing  the  specimens,  is  another  method 


URINE    ANALYSIS 


265 


whu'li 


uMi. ..  iiulicates  the  decree  of  functional  ability.  This  method  never  had  a 
scientihc  basis  and  has  been  largely  abandoned.  Electric  conductivity  of 
the  urine  and  blood  has  been  advised  as  an  additional  means  of  estimating 
functional  abilitv  of  the  kidneys,  but  as  the  results  are  also  based  on  molecular 
concentration,  tJiev  are  for  practical  puroses  identical  with  cryoscopy.  Uro= 
toxic  coefficent  "(B  ouch  a  r  d)  is  not  yet  sufficiently  precise  to  be  recom- 
mended as  a  practical  procedure,  to  say  nothing   of  the  difficulties  attending 

the  use  of  the  method. 

Conclusions.— A  perfectly  normal  urine,  including  normal  daily  excre- 
tion of  urea  and  chlorids,  justifies  the  conclusion  that  proper  eUmination 
exists.  If  corroborati\'e  evidence  is  desired  for  any  reason,  such  as  severe  opera- 
tive interference,  or  if  a  previous  renal  lesion  creates  a  doubt,  cryoscopy  of  the 
blood  should  show  normal  figures. 

In  unilateral  renal  disease  indicating  a  nephrectomy  the  followmg  steps  to 
determine  functional  ability  are  indicated  and  materially  aid  in  determinmg 
the  advisabilitv  of  operation  and  the  prognosis.  If  a  twenty-four  hour 
specimen  of  urine  contains  at  least  16  grams  of  urea,  and  if  the  freezmg- 
point  of  the  blood  is  normal  (minus  0.56°  C),  it  is  evident  that  the  sound 
kidney  is  capable  of  compensatory  elimination  and  the  diseased  one  can 
be  removed  with  safety.  Separate  collection  of  urine  from  each  kidney 
by  ureteral  catheterization  or  other  means  and  the  demonstration  by 
cryoscopy,  specific  gravity,  relative  amount  of  urea  and  chlorids,  that 
the  diseased  kidney  is  doing  but  little  excretory  work  compared  with  the 
sound  one,  strengthens  the  above  conclusion.  A  diminution  in  the  daily  excre- 
tion of  urea  below  16  grams,  and  any  increase  in  the  molecular  concentration 
of  the  blood  shown  by  a  lower  freezing-point  (minus  0.58°  C.  to  minus  0.61°  C), 
indicates  that  both  kidneys  are  unable  to  eliminate  properly  and  that  the  removal 
of  one  is  a  far  more  serious  matter.  K  li  m  m  e  1 1  and  others  consider  a  daily 
excretion  of  urea  below  16  grams,  and  a  blood  freezing-point  of  minus  0.59°  C. 
absolute  counterindications  to  nephrectomy,  and  show  greatly  improved 
statistics  of  renal  surgerv  in  consequence. 

Technic  of  Cryoscopy.— Either  the  Beckmann  thermometer  or  the 
Heidenhain  modification  may  be  used.  Both  are  graduated  in  hun- 
dredths of  a  degree  Centigrade  and  the  graduations  are  wide  enough  apart  to 
allow  readings  of  2^0  of  a  degree.  Sufficient  distilled  water  (10  to  20  c.c.)  to 
cover  the  bulb  of  the  thermometer  is  poured  into  a  glass  cylinder,  and  this 
cylinder  is  placed  in  another  slightly  larger  one,  so  that  an  air  space  is  made 
between  the  fluid  and  the  freezing-mixture,  which  insures  gradual  cooling. 
The  tubes  are  now  put  into  the  freezing-mixture  of  salt  and  ice  and  the  ther- 
mometer into  the  fluid  to  be  frozen,  where  it  is  held  in  place  by  a  rubber  stop- 
per which  also  carries  a  platinum  stirrer,  bent  in  such  a  way  as  not  to  touch 
the  sensitive  thermometer. 

The  apparatus  is  most  conveniently  set  up  as  shown  in  the  accom- 
panving  illustration  (Fig.  56),  so  that,  by  loosening  the  set-screw  of  the  ferrule 
on  the  rod  of  the  stand,  the  whole  apparatus  can  be  elevated  above  the  level  of 
the  freezing-mixture  in  the  glass  battery  jar.  Constant  stirring  with  the 
platinum  wire  is  necessary;  the  mercury  in  the  thermometer  rapidly  falls 
considerably  below  the  freezing-point,  when  it  suddenly  jumps  up,  and  momen- 
tarily rests  at  the  freezing-point,  which  must  be  accurately  noted.  It  now  falls 
slowly  to  the  temperature  of  the  freezing-mixture.     Several  precautions  must 


266 


LABORATORY  AIDS   IN   SURGICAL   DIAGNOSIS 


J. 


(H 


be  observed:  (1)  The  freezing-point  of  distilled  water  as  described  above  must 
be  obtained  before  every  examination.  (2)  The  described  jump  of  the  mercury 
must  occur  if  the  technic  is  proper,  when  testing  the  water  as  well  as  when  test- 
ing blood  or  urine ;  if  it  does  not  take  place,  the  specimen  has  not  been  properly 

stirred.  (3)  The  bulb  of  the  thermom- 
eter must  not  come  in  contact  with  the 
container  or  the  stirring  wire.  (4)  The 
LJ-shaped  glass  cylinder  is  preferable 
to  a  |_J -shaped  large  test-tube,  as 
more  thorough  stirring  is  possible. 
The  specimen  to  be  examined  is  tested 
in  the  same  way  and  the  difference  be- 
tween the  freezing-points  obtained 
indicates  the  molecular  concentra- 
tion. For  example,  the  freezing-point 
of  distilled  water  under  existing  con- 
ditions of  atmosphere  and  Beckmann 
thermometer  is,  we  will  say,  4.015°  C, 
while  that  of  a  specimen  of  blood  is 
3.455°  C:  4.015—3.455  =—0.56°  C, 
the  freezing-point  of  the  specimen  of 
blood.  The  blood  is  most  conveniently 
obtained  from  one  of  the  large  veins 
at  the  bend  of  the  elbow  by  means  of 
an  aspirator,  or  preferably  by  using 
Thatcher's  ''mosquito,"  shown  in 
Fig.  57. 

Technic  in  Examining  Small 
Amounts  of  Urine  as  Obtained  by 
Ureteral  Catheterization. — As  the 
collection  of  urine  under  the  circum- 
stances is  a  tedious  matter  to  both  sur- 
geon and  patient,  the  analyst  must 
arrange  to  obtain  his  information  from 
very  small  amounts.  With  care  and 
practice  it  is  surprising  how  much  can 
be  done  with  little  urine,  and  10  c.c.  of 
urine  usually  suffices,  though  every  ad- 
ditional drop  makes  the  procedure  an 
easier  one.  The  specific  gravity  is  first 
taken  with  a  Westphal  balance,  and 
the  whole  is  then  centrifuged  to  obtain 
the  sediment  for  microscopic  examina- 
tion. After  removal  of  the  sediment, 
the  whole  may  be  accurately  diluted 
with  distilled  water  at  a  given  temper- 
ature, and  the  amount  is  next  divided 
for  the  tests  for  urea,  chlorids,  albumin,  etc.  Precision  is  essential,  as  errors 
are  liable  to  be  greater  owing  to  the  small  amounts  of  the  specimens  used. 


Fig.  56. — Apparatus  for  Crtoscopt. 


URINE   ANALYSIS 


267 


Hematuria,  or  the  presence  of  blood  in  the  urhie,  is  a  frequent  symptom, 
the  cause  of  which  the  surgeon  is  asked  to  determine.  Chnical  methods  have 
made  great  headway,  and  the  present  universal  use  of  the  cystoscope  makes 
the  diagnosis  a  much  easier  one  than  it  was  twenty  years  ago.  The  character- 
istics presented  by  the  urine  are,  however,  worthy  of  close  attention,  and  while 
its  critical  examination  will  not  reveal  the  seat  of  the  bleeding  in  every  in- 
stance, much  information  of  value  is  always  obtained.  That  the  more  arterial 
the  color  of  the  blood,  the  lower  in  the  urinary  tract  is  its  origin,  is  an  old  rule. 
This  holds  good  except  in  some  cases  of  severe  hemorrhage  from  renal  neoplasm, 
and  in  that  seen  in  renal  traumatism.  In  vesical,  prostatic,  and  urethral 
hemorrhage  the  blood  usually  shows  immediate  tendency  to  coagulation,  whereas 
in  renal  hemorrhage  it  is  more  intimately  mixed  with  the  urine  and  coagulates 
only  when  the  bleeding  has  been  profuse.  In  hemorrhage  from  the  renal  pelvis 
due  to  calculus,  etc.,  unless  very  profuse,  the  blood  is  intimately  mixed  with  the 
urine,  and  is  much  brighter  in  color  than  that  in  the  smoky  hematuria  of  acute 
inflammatory  lesions  of  the  renal 
parenchyma.  The  microscopic  ex- 
amination of  the  urine  often  shows 
evidences  of  the  diseased  condition 
which  is  the  cause  of  the  hemorrhage, 
and  in  this  case  it  is  reasonable  to  infer 
that  the  bleeding  is  of  the  same  origin . 

Pyuria,  or  the  presence  of  pus 
in  the  urine,  is  also  a  frequent 
symptom,  the  cause  of  which  the 
surgeon  is  asked  to  determine.  As 
in  the  case  of  hematuria,  the  cysto- 
scope and  other  clinical  methods 
are  of  much  value  in  the  diagnosis. 
The  methodic  analysis  of  the  urine 
is  also  an  important  feature,  as  shown 
below,  and  the  structural  elements 
accompanying  the  pus,  as   well  as 

many  general  characteristics  presented  by  the  twenty-four  hour  specimen, 
usually  justify  an  inference  as  to  its  origin.  Pus  of  vesical  or  prostatic  origin 
usually  undergoes  coagulation  quite  rapidly,  while  that  from  the  kidney  is  more 
intimately  mixed  w4th  the  urine  and  remains  diffused  throughout  the  specimen. 

Post=anesthetic  nephritis  is  today  a  much  less  frequent  condition 
than  it  was  fifteen  years  ago,  an  improvement  which  can  doubtless  be  ascribed 
to  the  more  careful  use  of  anesthetics,  quicker  operating,  the  free  administra- 
tion of  water  by  mouth  or  rectum  after  operation,  and  proper  early  attention  to 
the  bowels.  There  are  but  few  cases  in  which  a  faint  trace  of  albumin  with  or 
without  few  hyaline  or  epithelial  studded  casts  cannot  be  demonstrated  after 
anesthesia,  due  to  some  renal  hyperemia.  Comparatively  few  cases  present 
all  the  characteristic  evidences  of  an  acute  toxic  nephritis.  Diminished 
quantity  of  urine,  high  specific  gravity,  high  relative  and  low  absolute  excretion 
of  urea  and  chlorids,  the  presence  of  albumin,  often  in  large  amount,  with  a 
profuse  sediment  consisting  of  blood,  a  few  pus-cells,  and  all  varieties  of  casts, 
are  the  prominent  symptoms.     If  the  patient's  general  condition  is  good, 


Fig.  57. — Thatcher  "Mosquito 


268  LABORATORY   AIDS   IN    SURGICAL    DIAGNOSIS 

post-anesthetic  nephritis  iisuaUy  responds  to  treatment  more  quickly  than  in 
the  case  of  nephritis  as  ordinarily  met  with  in  medical  practice.  Every  surgeon 
of  considerable  experience  recalls  a  case  in  which  the  use  of  an  anesthetic  was 
followed  by  an  absolute  anuria  and  death.  Pathologic  examination  reveals 
an  intense  hvperemia,  but  this  seems  scarcely  sufficient  to  explain  the 
clinical  condition,  especially  if  the  patient  presented  no  evidences  of  a  previous 
renal  lesion. 

Acute  and  Chronic  Nephritis  and  Its  Influence  in  Surgical  Prognosis. 
— This  is  a  question  which  not  infrequently  confronts  the  surgeon,  and  while 
the  clinical  manifestations  of  this  complicating  disorder  merit  close  attention, 
much  information  is  obtained  l^y  laboratory  methods.  A  thorough  and  pref- 
erably repeated  examination  of  the  urine,  not  omitting  quantitative  determi- 
nations of  the  daily  amounts  of  urea  and  chlorids,  offers  a  good  guide  to  the 
status  of  excretory  abihty.  The  more  recently  advocated  cryoscopy  of  the 
blood  can  be  warmly  recommended,  and  if  the  freezing-point  is  found  below 
minus  0.56°  C,  the  prognosis  of  the  contemplated  surgical  procedure  becomes 
affected  in  direct  proportion  to  the  freezing-point  depression.  Chloroform 
employed  as  an  anesthetic  is  less  irritating  to  the  kidney  than  ether,  but  any 
anesthetic  agent  is  liable  to  produce  some  exacerbation  of  the  renal  inflamma- 
tion. 

Diabetes  Mellitus  and  Its  Influences  in  Surgical  Prognosis.— 
The  presence  of  true  diabetes  as  distinguished  from  simple  glucosuria,  glucuronic 
aciduria,  and  pentosuria,  always  exerts  a  decided  influence  on  the  prognosis  in 
contemplated  operative  interference.  It  is  a  serious  error  to  judge  the  severity 
of  this  disease  by  the  percentage  of  glucose,  or  the  quantity  of  sugar  excreted  in 
twenty-four  hours,  as  the  most  dangerous  cases  sometimes  excrete  a  com- 
paratively small  amount  of  glucose  at  the  time.  Careful  examination  for 
evidences  of  acid  intoxication,  as  shown  by  the  presence  of  acetone,  diacetic 
acid,  and  beta-oxybutyric  acid,  must  be  made,  as  this  constitutes  the  best 
guide  in  determining  the  prognosis.  The  patient  who  is  excreting  a  large 
amount  of  glucose  without  acetone  or  diacetic  acid  in  the  urine,  is  a  much  better 
subject  for  the  surgeon  than  the  patient  who  shows  but  very  little  glucose  with 
larger  amounts  of  acetone,  diacetic  and  beta-oxybutyric  acids. 

Evidences  of  Toxemia,  Before  and  After  Operations.— A  fairly 
constant  train  of  symptoms  is  at  times  associated  with  surgical  lesions  which 
cannot  be  referred  to  the  pathologic  process,  and  is  now  ascribed  to  faulty 
metabolism  or  toxemia.  The  causative  factor  is  unknown,  but  the  clinical 
manifestations  are,  briefly,  severe  headache,  malaise  often  amounting  to  somno- 
lence, and  vomiting,  usually  with  considerable  nausea.  It  was  originally  be- 
lieved that  all  these  symptoms  were  referable  to  some  local  disorder  in  the 
stomach  or  bowel,  and  while  it  is  true  that-  the  toxin  may  originate  there,  a 
cause  for  such  development  is  not  apparent.  The  evidences  in  the  urine  would 
tend  to  divide  the  cases  into  two  classes:  (1)  A  decided  increase  in  the  daily 
amount  of  uric  acid,  as  shown  by  a  lowered  urea  and  uric  acid  ratio,  and  the 
presence  of  acetone,  diacetic  acid,  and  sometimes  beta-oxybutyric  acid.  (2) 
A  decided  increase  in  the  daily  excretion  of  indoxyl  sulfate  and  skatoxyl  sul- 
fate, as  shown  by  pronounced  indican  and  skatol  reactions  in  the  urine  and  a 
lowered  ratio  of  mineral  and  ethereal  sulfates.  A  combination  of  both  is, 
however,  frequently  seen,  and,  as  a  rule,  the  first  described  class  presents  the 
most  pronounced  sj^mptoms. 


URINP]    ANALYSIS  269 

Acute  Cystitis. — The  (lail>-  amount  of  uriiic,  (he  density,  and  the 
daily  excretion  of  solids  are  normal,  and  the  amount  of  albumin  present  corre- 
sponds to  what  might  be  accounted  for  by  the  blood,  pus,  etc.  A  microscopic 
examination  of  the  sediment  shows  blood,  pus,  mucus,  and  many  epithelial 
cells  referable  to  the  bladder.  At  first  the  reaction  is  usually  acid,  but  it  may 
become  alkaline  with  the  addition  of  triple  phosphates  in  the  deposit,  unless 
the  colon  bacillus  is  the  causative  factor,  in  which  case  it  remains  acid  and  has 
an  offensive  odor.  Elements  of  other  causative  factors  can  also  usually  be 
demonstrated. 

Chronic  Cystitis. — The  urinary  picture  is  much  the  same  as  in  acute 
cystitis,  but  there  is  usually  no  blood  present.  If  the  lesion  is  tuberculous  or 
due  to  the  colon  bacillus,  the  reaction  is  usually  acid,  but  otherwise  an  alkaline 
fermentation  develops  in  the  bladder  and  many  triple  phosphate  crystals  will 
be  found  in  the  sediment,  the  specimen  having  a  very  offensive  odor. 

A  differential  diagnosis  of  chronic  cystitis  and  pyelitis  with  hyperemia  of 
the  renal  parenchyma  is  not  always  easy,  because  a  cystitis  so  frequently 
accompanies  the  pyelitis. 

Chronic  Cystitis.  Pyelitis  with  Hyperemia. 

Daily  amount  of  urine .  .  Normal.  Increased. 

Specific  gravity Norinal.  Lowered. 

Daily  amount  of  solids .  .  Normal.  Normal. 

Reaction Alkaline.  Acid. 

Albumin According  to  amount  of  pus.  More  than  pus  would  account  for. 

Sediment Coagulates  quickly.  Diffuse,  not  coagulated. 

Renal  elements None.  Few  casts,  and  epithelial  cells  from 

pelvis. 

Pus  due  to  cystitis  always  shows  many  structural  elements  referable  to 
the  bladder,  wdiile  pus  due  to  pyelitis  shows  but  few  epithelial  cells  at  best. 

Acute  Catarrli  of  tlie  Renal  Pelvis. — The  urinary  picture  is  somewhat 
different  according  as  this  lesion  is  due  to  a  local  cause  or  to  an  ascending 
infection.  In  the  event  of  a  local  cause,  such  as  calculus  or  pronounced  crystal- 
line deposits,  the  daily  amount  of  urine  is  decreased,  there  is  corresponding 
concentration,  normal  daily  output  of  solids,  blood-cells  according  to  the 
amount  of  local  abrasion,  few  leukocytes,  some  mucus,  characteristic  groups 
of  epithelial  cells,  and  an  amount  of  albumin  and  casts  according  to  the  degree 
of  hyperemia  of  the  parenchyma,  some  evidences  of  which  invariably  accom- 
pany the  condition.  In  the  event  of  an  ascending  infection,  pyogenic,  gonor- 
rheal, or  colon  bacillus,  the  urine,  showing  the  evidences  of  the  original 
bladder  lesion,  suddenly  becomes  scanty,  with  some  increase  in  the  amount 
of  albumin,  the  presence  of  few  casts,  and,  if  one  is  fortunate  enough  to 
recognize  them,  epithelial  cells  referable  to  the  renal  pelvis,  with  a  normal 
daily  output  of  solids.  In  either  case  this  condition  does  not  last  long;  the 
evidences  of  the  acute  catarrh  disappear  or  the  picture  soon  becomes  that  of 
pyelitis. 

Pyelitis  with  Hyperemia  of  the  Renal  Parenchyma. — The  daily 
amount  of  urine  is  increased,  the  specific  gravity  lowered,  and  the  daily  excre- 
tion of  the  solids  is  normal.  The  microscopic  picture  shows  pus  in  addition  to 
the  elements  found  with  catarrh  of  the  pelvis.  The  pus  usually  also  shows  the 
characteristics  of  its  renal  origin,  as  detailed  under  the  heading  of  Pyuria. 


270  LABORATORY    AIDS   IN    SURGICAL    DIAGNOSIS 

Pyelonephritis. — The  twenty-four  hour  specimen  of  urine  presents 
features  siniihir  to  those  noted  in  pyelitis,  with  the  addition  of  the  elements 
referable  to  the  lesion  of  the  parenchyma,  i.  <?.,  an  increased  amount  of  albumin 
and  a  greater  number  and  variety  of  casts,  though,  as  in  other  forms  of  chronic 
nephritis,  there  may  be  but  very  few  casts  at  times.  In  the  event  of  com- 
pensating excretory  action  of  the  other  kidney,  which  always  exists  in  uni- 
lateral renal  lesions,  the  daily  excretion  of  urea  and  chlorids  remains  normal  or 
nearly  so.  Some  of  the  specific  varieties  of  pyelonephritis  are  considered  in 
greater  detail  below. 

Hydronephrosis  and  Pyonephrosis. — If  the  ureter  on  the  affected  side 
is  occluded,  the  urine  voided  may  be  perfectly  normal,  but  there  is  usually  a 
moderate  polyuria  with  evidences  of  a  slight  hyperemia  of  the  renal  parenchyma 
due  to  the  additional  excretory  labor  on  the  part  of  the  acting  kidney.  An 
intermittent  hydronephrosis,  especially  if  there  is  an  accompanying  hematuria, 
which  is  by  no  means  rare,  presents  a  urinary  picture  which  is  more  likely 
to  confuse  the  diagnosis  than  to  aid  it. 

A  pyonephrosis  suddenly  emptying  into  the  bladder  also  presents  a  very 
meager  microscopic  picture,  but  the  necrotic  character  of  the  pus  is  often  cor- 
roborative evidence,  though  a  differential  diagnosis  of  this  condition  and  an 
abscess  perforating  into  the  upper  urinary  tract  is  most  difficult. 

Polycystic  Degeneration  of  Kidney,  Syphilitic  Renal  Hyperplasia 
Simulating  Malignant  Growth,  and  Cysts  of  the  Kidney. — In  these  cases 
there  is  usually  very  little  or  nothing  in  the  urine  analysis  of  value  in  the  specific 
diagnosis.  They  present  the  evidences  of  the  type  and  severity  of  the  accom- 
panying chronic  nephritis  which  frequently  but  not  invariably  exists. 

Renal  Actinomycosis. — The  urine  presents  the  features  of  pyelitis 
with  hyperemia  of  the  parenchyma,  or  those  of  pyelonephritis  with  more  or 
less  frequent  hematuria  of  renal  origin.  Much  patience  is  necessary  in  identify- 
ing the  fungus  and  thus  establishing  the  diagnosis,  for  this  is  usually  no  easy 
matter  even  for  the  expert  microscopist. 

Floating  Kidney. — An  examination  of  the  urine  discloses  no  char- 
acteristic features,  but  frequent  attacks  of  transient  neurotic  potyuria  are 
observed  in  some  cases. 

Malignant  Tumors  of  the  Kidney. — An  intermittent  renal  hematuria, 
often  of  very  brief  duration,  is  the  most  constant  abnormal  feature  in  the 
urine.  The  hematuria  is  usually  quite  profuse,  and  in  consequence  may 
present  clots  and  even  casts  of  the  ureter  or  pelvis.  In  typic  cases  the  urine 
is  otherwise  normal,  or  perhaps  more  frequently  shows  the  evidences  of  a  slight 
hyperemia  of  the  renal  parenchyma.  The  presence  of  microscopic  blood 
between  the  attacks  of  pronounced  hematuria  is  a  very  suggestive  feature. 
Even  if  the  hemorrhage  is  quite  slow,  the  blood  looks  red,  and  is  not  smoky, 
as  in  acute  nephritis.  The  coexistence  of  pyelitis  or  pyelonephritis  is  really 
foreign  to  the  condition  under  consideration,  and  when  present  is  brought  about 
by  an  ascending  infection,  perhaps  due  to  lack  of  resistance  on  the  part  of 
the  mucous  membrane,  or  is  the  result  of  a  local  suppurating  lesion  in  the 
tumor.  A  few  cases  present  marked  albuminuria  without  corroborative 
evidence  of  nephritis  in  the  remaining  healthy  parenchyma.  In  fact,  the 
urine  analysis  in  cases  of  this  kind  teaches  less  of  diagnostic  value  than  is  usually 
ascribed  to  it.     When  sufficiently  preserved  shreds  of  tumor  are  passed,  the 


PLATE  IV 


Typic  Urinary  Sediments  in  the  Following  Conditions  : 


'  A.  Acute  cystitis.     Blood,  pus  and  mucus.    Note 
the  large  number  of  epithelial  cells. 

C.  Acute  pyelitis  and  hyperemia  of  parenchyma 
due  to  stone  colic.  Blood,  pus,  very  little  mucus,  and 
few  hyaline  casts  with  decided  oxalate  of  lime  crys- 
talline deposit.  Note  the  comparatively  few  epithe- 
lial cells. 


B.  Chronic  cystitis.  Pus  with  much  mucus. 
Note  the  large  number  of  epithelial  cells. 

D.  Chronic  pyelonephritis  with  colon  bacillus 
bacteriuria.  Pus,  but  little  mucus,  numerous  hyaline 
and  granular  easts  and  bacteria.  Note  the  comjiara- 
tively  few  epithelial  cells. 


URINE    ANALYSIS  271 

conclusions  arc  obvious,  but  this  occurrence  is  b\'  no  means  so  frccjuent  as  the 
text-books  would  lead  one  to  believe.  An  erroneous  laboratory  diagnosis  of 
malignant  tumor  of  the  kidney  based  solely  on  the  structure  of  one  or  a  number 
of  epithelial  cells  found  in  the  urine  has  annoyed  many  a  surgeon,  the  "cancer 
cell  "  and  tlie  "  sarcoma,  cell"  l)eing  myths  for  practical  purposes. 

Renal  Tuberculosis. — With  what  is  often  the  first  clinical  symptom 
— nocturnal  frequency  of  urination — the  urine  may  be  perfectly  normal  in  daily 
amount  and  chemic  composition,  the  few  blood-cells  found  microscopically 
constituting  the  only  noteworthy  feature  apparent.  The  urinary  picture  very 
soon  changes  to  that  of  pyelitis  with  hyperemia  of  the  parenchyma,  the 
rather  marked  polyuria  and  the  presence  of  at  least  a  few  blood-cells  being 
practically  constant.  Later  the  specimen  presents  all  the  evidences  of  pyelo- 
nephritis. The  process  of  finding  tubercle  bacill  in  the  sediment  has  been 
simplified  b}'  the  introduction  of  the  centrifuge,  and  success  is  largely  due  to  the 
patient  and  painstaking  search  made  for  them.  The  cases  of  renal  tuberculosis 
in  which  bacilli  are  not  found  when  a  number  of  specimens  have  been  examined 
are  not  so  numerous  as  usually  believed,  and  the  fault  lies  in  lack  of  thoroughness 
in  the  investigation.  There  are  cases,  however,  in  which  bacilli  cannot  be  found 
on  repeated  careful  search,  and  in  these  animal  inoculation  is  often,  though 
by  no  means  invariably,  successful.  Tuberculous  urine  usually  has  an  acid 
reaction  and  does  not  show  a  macroscopic  bacteriuria.  When  a  mixed  infection 
does  occur  and  the  specimen  is  foul,  an  attempt  should  be  made  to  get  it  into 
better  condition  before  animal  inoculation  is  undertaken.  In  the  event  of 
animal  inoculation,  experience  teaches  that  the  macroscopic  result  is  not 
sufficient,  but  the  presence  of  actual  tubercles  must  be  demonstrated  micro- 
scopically. Concerning  the  differentiation  of  tubercle  bacilli  and  smegma 
bacilli,  the  decolorization  of  the  latter  with  absolute  alcohol  usually  presents 
no  difficulty,  but  in  case  of  a  marked  alkaline  fermentation  the  tubercle  bacilli 
do  not  so  well  withstand  the  action  of  alcohol.  An  opinion  based  on  the 
presence  of  single  bacilli  must  be  very  guarded,  but  usually  the  organisms 
occur  in  groups  which  present  specific  characteristics,  as  shown  in  the  accom- 
panying illustrations.  (Plate  V.)  The  diagnosis  of  tuberculous  renal 
disease  can  usually  be  made  from  the  urine,  and  success  is  due  rather  to 
patient  investigation  than  to  particular  skill. 

Renal  Calculus. — In  this  condition  the  urinary  picture  is  most  varied 
according  to  the  pathologic  process  which  has  developed  in  consequence  of  the 
presence  of  the  foreign  body,  and  that  due  to  a  complicating  infection.  On  the 
one  hand,  perfectly  normal  urine  may  be  voided  or  there  may  be  evidences 
of  a  slight  hyperemia  of  the  renal  parenchyma;  on  the  other,  the  most 
severe  pyelonephritis  and  cystitis  with  a  marked  alkaline  fermentation  may  be 
seen,  in  which  it  is  often  difficult  to  find  any  structural  elements  in  the  vast 
amount  of  very  offensive  coagulated  pus  and  masses  of  triple  phosphate  crystals. 
At  the  time  of  a  renal  colic  the  picture  is  ordinarily  that  of  an  acute  catarrh  of 
the  renal  pelvis,  with  more  or  less  hyperemia  of  the  parenchyma,  the  amount  of 
blood  being  in  direct  proportion  to  the  mechanic  injury.  After  the  attack  of 
pain  these  evidences  disappear  more  or  less  quickty,  or  pyelitis  is  developed, 
to  remain  or  gradually  clear  up  as  the  case  may  be.  In  the  chemic  analysis  of 
specimens  from  cases  of  renal  stone  the  almost  constant  high  relative  as  well 
as   the   absolute  nitrogenous  output  is  a  noteworthy  feature  which  can  be 


272  LABORATORY   AIDS   IN    SURGICAL    DIAGNOSIS 

looked  to  with  considerable  success  as  an  important  point  in  differential 
diagnosis.  It  stands  to  reason  that  a  patient  whose  mode  of  life  has  been  suit- 
ably corrected  does  not  present  these  characteristics,  or  presents  them  only  to 
a  moderate  degree.  The  presence  in  the  urine  of  pronounced  crystalline 
deposits,  while  forming  a  link  in  the  chain  of  evidence,  justifies  conclusions  in 
only  a  small  number  of  cases.  Triple  phosphate  deposits  are  the  result  of  an 
alkaline  fermentation  due  to  any  cause,  and  merit  no  consideration  in  this 
connection.  An  intermittent  hydronephrosis  often  empties  with  a  colic  and 
frequent  micturition,  and  at  this  time  is  liable  to  show  some  blood.  The  dif- 
ferential point  between  this  colic  and  a  stone  colic  is,  that  in  the  former  the 
amount  of  urine  is  usually  large  and  the  gravity  low,  whereas  in  the  latter  the 
opposite  is  an  almost  invariable  rule. 

Nephralgia  and  Allied  Conditions. — The  etiology  of  these  conditions 
is  still  a  subject  of  dispute,  and  the  urinar}^  findings  often  closely  resemble 
those  noted  in  other  lesions,  so  that  a  differential  diagnosis  is  difficult  at  best, 
and  at  times  impossible.  The  absolutely  pessimistic  view  held  by  many 
is  clue  to  the  negative  outcome  of  one  or  two  specimens,  while  the  clinical 
examination  has  been  repeated  over  and  over  with  no  better  result.  Careful 
and  often  repeated  analysis,  while  possibly  leading  to  no  positive  result,  tends 
to  exclude  other  conditions,  and  is  oftentimes  of  greater  practical  utility  than 
all  the  clinical  work.  During  an  attack  of  nephralgia  the  urine  may  be  per- 
fectly normal,  but  this  is  also  true  in  renal  colic  due  to  stone,  though  much  less 
frequently.  A  neurotic  polyuria  may  occur  at  the  time  of  a  nephralgic  par- 
oxysm, whereas  no  simulating  condition  is  noted  in  stone  colic.  On  the  other 
hand,  cases  of  nephralgia  with  hematuria  and  scanty  urine  are  not  unknown, 
but  experience  teaches  that  they  never  show  the  almost  immediate  evidences  of 
an  inflammatory  lesion  noted  in  the  same  condition  due  to  calculus. 

Hematuria  Due  to  Atrophic  Kidney. — The  pronounced  hematuria 
seen  at  times  in  this  condition,  as  well  as  that  noted  in  an  acute  exacerbation 
of  an  older  renal  lesion,  the  former  red,  the  latter  smoky,  must  be  kept  in 
mind  when  seeking  the  cause  of  a  renal  hematuria. 

Subcutaneous  Traumatism  of  the  Kidney. — In  subcutaneous  renal 
injuries  the  first  urine  voided  shows  a  pure  hematuria,  and  the  subsec{uent 
picture  depends  largely  on  the  nature  and  the  result  of  the  lesion  and  on  the 
presence  or  absence  of  a  bacterial  infection. 

Suppurative  Nephritis. — This  name  is  frequently  given  to  cases  in 
which  multiple  miliary  abscesses  develop  throughout  the  kidney  in  conjunction 
with  an  acute  pyelonephritis  due  to  streptococcus  invasion.  The  urine  shows 
the  elements  found  in  pyelonephritis,  the  clinical  symptoms  usually  being  more 
profound  than  the  urinary  picture  would  seem  to  justify.  A  careful  examina- 
tion of  the  bood  presents  the  evidences  of  the  severe  septic  process,  and  is  often 
the  cardinal  indicator  for  the  prompt  surgical  relief  which  these  cases  demand. 

Colon  bacillus  infection  of  the  urinary  tract  is  a  common  occur- 
rence, and  may  not  only  be  the  cause  of  a  severe  cystitis,  but  may  result  in  a 
pyelonephritis  as  well.  The  urine  shows  the  evidences  of  the  existing  lesions 
with  an  acid  reaction,  an  offensive  odor,  and  a  macroscopically  apparent  bacteri- 
uria.  Direct  culture  attempts  for  diagnosis  by  stab  inoculation  of  glucose  agar 
should  show  a  nonliquefying,  offensive  gas-producing  growth,  but  the  accurate 
differential  diagnosis  belongs  to  the  domain  of  bacteriology. 


PLATE  V 


■\v.  ~'^'' 


#    ^  ^ 


m^  u 


^5.< 


Wl 


A.  Typic  Groups  of  Tubercle  Bacilli, 

B.  Usual  Grouping  of  Smegma  Bacilli, 


EXAMINATION    OF    SPUTUM 


273 


SCHEIMATIC  TA1M>1':  OF  URINARY  PICTURE  IN  THE  MORE  IMPORTANT 
SUIIGICAL  DISEASES  OF  THE  URINARY  TRACT. 


Daily 

Specific 

Daily 

Abnormal  Constituents. 

Disease. 

Amount  of 

UlUNE. 

Reaction. 

Amount  of 
UnEA. 

Gravity. 

Albumin. 

Microscopic. 

Acute  cj'stitis. 

Normal. 

Normal. 

Acid,  occa- 
.sionly  al- 
kaline. 

Normal. 

Equal    to 
a  m  o  u  n  t , 
pus    a  n  d 
blood. 

Blood,  pus, 
mucus,  and 
many  blad- 
der epithelial 
cells.  Evi- 
dences of  the 
causative 
factor. 

Chronic  cystitis. 

Normal. 

Normal. 

Alkaline 
unless 
colon  ba- 
cillus  or 
tubercu- 
losis. 

Normal. 

Equal   to 
amount  of 
pus,  etc. 

No  blood, 
otherwise  as 
above.  Also 
bacteria,  and 
if  alkaline, 
triple  phos- 
phates. Evi- 
dences of 
causative 
factor. 

Acute     catarrh 

Decreased. 

High. 

Acid. 

Normal  or 

More    than 

Blood,    pus, 

of  renal  pelvis 

dimin- 

blood and 

few    pelvic 

with     hyper- 

ished. 

pus  would 

epithelial 

emia   of    the 

Usually 

account 

cells,     few 

parenchyma. 

increased 
if  stone. 

for. 

hyaline  or 
epithelial 
casts.  Hem- 
aturia with 
stone  colic. 
Evidences  of 
causative 
factor. 

Pyelonephritis. 

Increased, 

Low. 

Acid 

Normal  if 

Consider- 

No    blood, 

particu- 

unilater- 

ably more 

otherwise 

larly    in 

al,  other- 

than   23US, 

as     above. 

tubercu- 

wise de- 

etc., would 

Larger  num- 

losis. 

creased. 
Usually 
increased 
if  stone. 

account 
for. 

ber  of  casts 
also  granu- 
lar. In  tu- 
berculosis 
and  neo- 
plasm usu- 
al 1  y  few 
blood-cells, 
occasionally 
hematuria. 
Evidences  of 
causative 
factor. 

EXAMINATION  OF  SPUTUM 

Specimens  must  be  considered  both  macroscopically  and  microscopically; 
the  former  ma}^  show  a  typic  picture  of  pulmonary  gangrene  by  the  offensive 
odor  and  the  presence  of  pieces  of  necrotic  tissue,  while  the  latter  may  give  the 
19 


274  LABORATORY    AIDS   IN   SURGICAL   DIAGNOSIS 

first  indications  of  pulmonary  tuberculosis.  The  following  conditions  are 
those  of  chief  interest  to  the  surgeon : 

Hemoptysis  due  to  perforating  aneurism  may  present  simply  a 
large  amount  of  arterial  blood,  with  or  without  the  history  of  a  previous 
catarrhal  condition  due  to  pressure  and  necrosis.  An  eroded  carotid  artery 
rupturing  into  an  open  retropharyngeal  abscess  presents  the  same  picture. 

Abscess  of  Lung. — The  expectoration  may  consist  solely  of  pus,  with 
little  or  no  odor,  which  is  raised  in  very  large  amounts,  often  as  much  as  a  pint 
in  twent3'-four  hours,  structural  elements,  blood-cells,  elastic  fibers,  fat  glo- 
bules, crystals  of  fatty  acids,  etc.,  also  being  found  microscopically.  Staining 
usually  shows  many  nonpathogenic  organisms  in  addition  to  pyogenic  forms, 
chiefly  the  staphylococcus.  Chronic  lung  abscesses  present  much  the  same 
picture,  with  the  occasional  addition  of  cholesterin  as  seen  microscopically,  but 
no  blood.  In  abscess  of  the  lung  evidences  of  actinomycosis  and  echinococcus 
should  always  be  looked  for. 

Empyema  Rupturing  into  the  Lung. — The  specimens  as  well  as  the 
sudden  manner  of  expectoration  resemble  what  is  seen  in  abscess  of  the  lung, 
and  a  differential  diagnosis  is  oftentimes  quite  difficult.  The  amount  of  pus 
expectorated  at  one  time  is  seldom  as  large  as  noted  in  abscess,  but  the  daily 
amount  may  be  larger. 

Echinococcus  cysts  in  the  liver  sometimes  perforate  into  the  pleura  and  in 
turn  into  the  lung.  The  sputum  has  a  peculiar  yellow  color  and  the  evidences 
of  echinococcus  are  usually  easily  found. 

Neoplasm  of  the  Lung. — The  sputum  is  likely  to  contain  small  or 
large  amounts  of  blood,  and  the  presence  of  microscopic  blood  between  the 
more  profuse  hemorrhages  is  a  suspicious  sign.  Very  rarely  indeed  sufficien«t 
tumor  tissue  is  expectorated  for  diagnostic  purposes,  and  a  warning  must  be 
sounded  against  so-called  "carcinoma  cells." 

The  characteristics  found  in  the  sputum  in  pulmonary  tuberculosis,  pneu- 
monia, bronchitis,  etc.,  belong  to  the  domain  of  general  medicine. 

EXAMINATION  OF  GASTRIC  CONTENTS 

When  the  modern  methods  of  gastric  analysis  resulted  in  greater  accuracy  in 
the  diagnosis  of  diseases  of  the  stomach,  it  was  believed  that  the  two  diseases 
which  particularly  interest  the  surgeon,  namely,  ulcer  and  cancer,  could  be  posi- 
tively diagnosed  at  an  earlier  period  in  the  laboratory  than  by  clinical  means. 
The  absence  of  hydrochloric  acid  and  the  presence  of  lactic  acid  were  con- 
sidered positive  indicators  of  carcinoma,  while  the  presence  of  an  excessive 
amount  of  hydrochloric  acid  indicated  ulcer.  Time  proved  that  this  rule,  like 
most  others,  had  its  glaring  exceptions,  and  the  opinion  of  today  is  that  the 
result  of  the  gastric  analysis  must  take  its  place  with,  the  clinical  signs  and 
symptoms,  to  be  considered  for  what  experience  has  taught  it  is  w^orth. 

The  procedure  is  as  follows:  The  patient  is  given  an  E  wal  d  test  breakfast 
consisting  of  one  baker's  roll  without  butter,  weighing  about  35  grams,  and  300 
c.c.  of  water  or  weak  tea  without  milk  or  sugar,  on  an  empty  stomach.  One 
hour  after  ingestion  the  contents  of  the  stomach  are  expressed  by  tube  without 
the  use  of  water.  While  a  more  elaborate  examination  may  be  useful,  at  least 
the  following  determinations  should  be  made: 


EXAMINATION    OF    GASTRIC    CONTENTS 


275 


Total  quantity  (normal,  40  c.c.  to  200  c.c). 

Total  quantity  of  filtrate  (normal,  20  c.c.  to  140  c.c.)- 

Free  hydrochloric  acid  (normally  present). 

Lactic  acid  (normally  absent). 

Total  acidity  (normal,  1.5  to  3.0  grams  per  mille).     Scheme  "A 

Total  hydrochloric  acid  (normal,  1.15  to  2.48  grams 
per  mille).     Scheme  "E." 

Total  free  hydrochloric  acid  (normal,  0.09  to    1.9 
grams  per  mille).     Scheme"!)." 

Total  combined  hydrochloric  acid  (normal,  0.24  to 
1.49  grams  per  mille).     Scheme  "C." 

Total  acidit}^  due  to  organic  acids  and  acid  salts  (nor- 
mal, 0.2  to  0.88  gram  per  mille).  Scheme  "F." 
Presence  of  free  hydrochloric  acid  {vide  infra)  is 
most  easily  demonstrated  with  T  6  p  f  e  r  '  s  test.  The  addi- 
tion of  one  or  two  drops  of  0.5  per  cent  alcoholic  solution  of 
dimethyl-amido-azo-benzol  to  'a  small  amount  of  gastric  con- 
tents immediately  produces  a  bright  cherry-red  color  if 
free  hydrochloric  acid  is  present.  This  test  is  preferable  to 
others  on  account  of  its  delicacy  and  the  stability  of  the 
reagent.  Lactic  acid  if  present  in  considerable  amount  will 
produce  an  orange  color,  but  if  any  doubt  exists  the  lactic 
acid  can  be  removed  b}'  treating  the  specimen  with  ether 
before  the  test  for  free  hydrochloric  acid  is  applied. 

Presence  of  lactic  acid  in  sufficient  amount  to  be  of 
clinical  importance  can  be  demonstrated  by  the  Strauss 
test.  The  graduated  separating  funnel  shown  in  the  illustra- 
tion (Fig.  58)  is  filled  to  the  5  c.c.  mark  with  filtered  gastric 
contents,  pure  ether  is  added  to  the  25  c.c.  mark  and  this 
is  thoroughly  shaken.  After  the  liquids  have  separated  the 
stopcock  is  ojDened,  and  all  but  5  c.c.  allowed  to  escape.  Dis- 
tilled water  is  now  added  to  the  25  c.c.  mark,  shaken,  and 
followed  by  2  drops  of  the  reagent,  consisting  of  a  freshly 
made  1  to  10  dilution  of  tincture  of  ferric  chlorid  in  water. 
The  presence  of  lactic  acid  is  show^n  by  a  decided  green  color. 


Fig.    58. 


Strauss 
Graduated  Tube 
FOR  Lactic  Acid 
Determination. 


SCHEMES 

"A."  Total  acidity.  To  10  c.c.  filtered  gastric  contents  add  2  drops  of  1  per 
cent  alcoholic  solution  phenolphthalein  (indicator).  Titrate  with  yV  normal 
sodium  hydrate.  For  example,  7  c.c.  iV  N.  NaOH  used.  7  X  0.00365  = 
0.0255  gram  total  acidity  in  10  c.c.  gastric  contents  expressed  as  HCl.  0.0255 
X  100  =  2.55  grams  total  acidity  per  mille  (per  thousand). 

"B."  Free  acids  and  acid  salts.  To  10  c.c.  filtered  gastric  contents  add  2  to 
3  drops  1  per  cent  aqueous  solution  sodium  alizarin  sulfonate  (indicator). 
Titrate  with  -rt,-  normal  sodium  hydrate.  For  example ,  4.9  c.c.  rb  N.  NaOH 
used.  4.9  X  0.00365  =  0.0178  gram  total  free  acids  and  acid  salts  in  10  c.c. 
gastric  contents  expressed  as  HCl.  0.0178  X  100  =  1.78  grams  total  free 
acids  and  acid  salts  per  mille  (per  thousand). 

''C."  Total  combined  hydrochloric  acid.      "A"  as  above  2.55  minus  "B" 


276  LABORATORY    AIDS    IX    SURGICAL    DIAGNOSIS 

as  above  1.78  =  0.77  gram  total  combined  hydrochloric  acid  per  mille  (per 
thou.sand) . 

"  D."  Total  free  hydrochloric  acid.  To  10  c.c.  filtered  ga.stric  contents  add  a 
few  drops  0.5  per  cent  alcoholic  solution  dimethyl-amido-azo-benzol  (indicator). 
Titrate  with  tV  normal  sodium  hydrate.  For  example,  3.1  c.c.  tV  X.  XaOH 
used.  3.1  X  0.00365  =  0.0113  gram  total  free  hydrochloric  acid  in  10  c.c. 
gastric  contents.  0.0113  X  100  =  1.13  grams  total  free  hydrochloric  acid 
per  mille  (per  thousand). 

"E."  Total  hydrochloric  acid.  "C"  as  above  0.77  plus  "D"  as  above 
1.13  =  1.90  grams  total  hydrochloric  acid  per  mille  (per  thousand). 

"F."  Total  acidity  due  to  organic  acids  and  acid  salts.  "B"  as  above 
1.78  minus  "D"  as  above  1.13  =  0.65  gram  total  acidity  due  to  organic  acids 
and  acid  salts  per  mille  (per  thousand). 

Some  experience  is  necessary  to  determine  the  proper  end  reactions  in  the 
above. 

EXAMINATION  OF  FECES 

The  macroscopic  as  well  as  the  microscopic  examination  of  the  stool  offers 
corroborative  evidence  in  diagnosis,  oftentimes  of  the  greatest  importance. 
The  following  resume  is  limited  to  the  features  of  particular  interest  to  the 
surgeon. 

Macroscopic  Examination. — Hemorrhage  from  the  lower  portion  of  the 
bowel  may  show  unchanged  Ijlood,  while  blood  derived  from  the  stomach  or 
small  intestine  may  be  totally  disintegrated  and  give  the  stool  a  dark  brown  or 
black  color,  a  sticky  character,  and  a  very  offensive  odor.  In  obstruction  to 
the  outlet  of  bile  the  stool  is  clay-colored  or  grayish-yellow.  In  suspected 
cholelithiasis  careful  search  should  be  made  for  concretions  by  stirring  the  feces 
with  water  and  straining.  Gallstones  occur  in  all  sizes,  and  usually  consist  of 
a  mixture  of  cholesterin  and  bile  pigment  with  salts.  Pus  and  mucus  derived 
from  the  lower  portion  of  the  intestinal  tract  are  usually  adherent  to  the  fecal 
masses,  but  if  derived  from  a  higher  portion,  they  are  intimately  mixed  with 
the  stool  and  m?.y  not  be  apparent  macroscopically.  Abscesses  rupturing 
into  the  intestine  usually  show  an  easily  recognized  mixture  of  pus  and  blood 
in  the  stool. 

Microscopic  Examination. — The  presence  of  ameba  may  corroborate  a 
diagnosis  of  abscess  of  the  liver.  Evidences  of  parasites  or  specific  bacteria 
often  explain  what  seem  to  be  obscure  conditions. 

Intestinal  ulcerations  in  the  small  gut  need  not  be  accompanied  by 
diarrhea,  but  those  in  the  large  intestine  are  always  accompanied  by  it. 
The  amount  of  pus  found  in  the  feces  is  no  guide  to  the  severity  of  the 
ulcerative  process. 

Intestinal  tuberculosis  usually  shows  the  evidences  of  ulceration  and 
tubercle  bacilli  are  easily  found.  In  referring  tubercle  bacilli  found  in  the  feces 
to  intestinal  lesions  it  must  be  remembered  that  swallowed  tuberculous  sputum 
may  occasion  the  presence  of  bacilli  in  the  stool.  In  examining  feces  for  tubercle 
bacilli,  the  mucopurulent  particles  should  be  selected  if  they  can  be  found. 
As  smegma  bacilli  also  occur  in  feces,  the  differentiation  by  alcohol  must  be 
made. 

Carcinoma  of  the  Intestine. — If  the  lesion  is  situated  in  the  upper  portion 
of  the  intestinal  tract,  the  stool  may  present  pus  and  altered  Ijlood  intimately 


EXAMINATION    OF  ASPIKATi:!)   FLUIDS  277 

mixed  with  it,  the  odor  usiuilly  Ixnng  very  offensive.  No  sio;nificance  can  be 
attached  to  the  "ribbonUke"  appearance  of  the  stool  formerly  considered 
pathognomonic.  In  carcinoma  of  the  rectum  small  amounts  of  offensive 
blood,  pus,  and  mucus  are  often  voided  with  tenesmus  without  an  admix- 
ture of  feces,  but  the  same  occur  in  proctitis  from  any  cause,  though  the  offen- 
siA'e  odor  is  not  present  unless  there  is  a  ruptured  periproctic  abscess.  Tumor 
particles  are  seldom  found,  and  a  warning  against  the  imaginary  "cancer  cell" 
is  again  sounded.  Passage  of  masses  of  blood  and  mucus  not  offensive  and 
without  tenesmus  is  sometimes  seen  with  intussusception. 

In  seeking  a  cause  for  intestinal  hemorrhage,  that  due  to  scurvy  and  allied 
conditions  must  be  kept  in  mind. 

While  the  modern  surgeon  is  interested  in  diseases  of  the  liver  and 
pancreas  which  alter  the  chemistry  of  the  feces,  the  significance  of  this  analytic 
work  still  belongs  to  the  domain  of  general  medicine. 


EXAMINATION  OF  ASPIRATED  FLUIDS 

The  chemic  and  microscopic  examination  of  aspirated  fluids  is  often  of  the 
greatest  help  in  diagnosis,  and  careful  work  generally  leads  to  the  most  gratify- 
ing results,  which  are  of  particular  interest  to  the  surgeon. 

Transudates  are  usually  straw-colored  serous  fluids  of  noninflammatory 
origin,  though  they  may  be  tinged  with  blood,  and  they  are  of  interest  here  on 
account  of  the  differential  diagnosis  between  them  and  the  serous  exudate  of 
inflammation.  This  differential  diagnosis  is  to  be  based  on  the  characteristic 
features  shown  in  the  following  table: 

Transudate.  Exudate. 

Specific  gravity 1005  to  1020.  lOlS  to  1030. 

Coagulation Unusual   except  when  blood  Usually  prompt  and  decided. 

present. 

Albumin 1  to  45  per  mille  liy  weight.  40  to  SO  per  mille  by  weight. 

Seromucin  (on  addition  of 

acetic  acid) None  or  traces.  Pronounced  reaction. 

Microscopically Few    leukocj'tes    and    endo-  Characteristics    as     detailed 

thelial  cells  from  the  serous  under  special  headings  and 

surface.  cj'todiagnosis. 

Exudates  are  usually  serous,  hemorrhagic,  or  purulent  in  character,  and 
all  are  of  inflammatory  origin.  If  purulent,  inflammatory  origin  is  obvious, 
while  the  serous  or  the  hemorrhagic  exudate  must  be  distinguished  from  a 
similarly  appearing  transudate  by  the  means  detailed  above. 

Cytodiagnosis  or  the  microscopic  study  of  the  cellular  elements  not 
only  aids  in  differentiating  transudate  and  exudate,  but  promises  to  give 
much  information  as  to  the  type  and  cause  of  the  latter.  The  main  feature 
is  the  predominance  of  the  lymphocyte  cell  or  of  the  polynuclear  cell,  and 
the  presence  or  absence  of  other  varieties  of  leukocytes.  Owing  to  the 
recent  development  of  this  study  the  opinions  are  still  divergent,  but  the  follow- 
ing conclusions  probably  represent  present-day  belief. 

In  acute  inflammatory  exudates  in  the  pleura  of  pneumococcic  or  strepto- 
coccic origin  the  polynuclear  leukoc^'te  usually  represents  90  per  cent  of  the 
total  count,  while  in  the  early  stage  of  tuberculous  pleurisy  the  polynuclear 


278  LABORATORY    AIDS   IN    SURGICAL    DIAGNOSIS 

percentage  is  rarely  50,  and  as  the  disease  jDrogresses  the  polynuclear  cells 
diminish  in  numbers  and  the  lymphocytes  represent  as  high  as  90  per  cent  of 
the  differential  count. 

In  malignant  disease  of  serous  membranes  the  microscopic  picture  of  the 
cellular  elements  in  the  exudate  is  often  looked  to  for  diagnosis.  Many  so- 
called  characteristic  features  have  been  described  and  the  differential  diagnosis 
of  cancer  cells  and  endothelial  cells  is  detailed  by  many.  An  erroneous  diag- 
nosis of  cancer  of  the  pleura  is,  however,  a  serious  matter,  and  as  long  as  the 
so-called  pathognomonic  cellular  indications  are  disputed,  it  is  well  to  accept  a 
diagnosis  on  this  basis  with  caution.  The  finding  of  tumor  particles,  which 
can  be  sectioned,  stained,  and  examined,  naturally  leaves  no  room  for  doul)t. 

The  significance  of  cytodiagnosis  in  cerebrospinal  fluid  will  be  detailed 
under  the  head  of  lumbar  puncture. 

Actinomycosis. — In  purulent  exudates  with  obscure  etiology  the  char- 
acteristics of  this  fungus  should  be  kept  in  mind  when  making  the  microscopic 
examination.  Aside  from  the  fungus,  the  specimens  present  nothing  particu- 
larly worthy  of  note. 

Putrid  exudates  are  obtained  from  the  pleural  cavity  when  hepatic  or 
subphi'enic  abscesses  have  perforated  into  this  cavity,  and  are  characterized  by 
a  brownish-green  color  and  an  extremely  offensive  odor. 

Chylous  exudates  are  observed  usually  in  the  abdominal  cavity,  but  their 
significance  depends  largely  on  the  clinical  factors,  and  this  examination  lends 
little  or  no  aid  in  the  diagnosis. 

Echinococcus  Cysts. — The  fluid  obtained  by  aspiration  is  usually  clear 
and  shows  numerous  crystals  of  cholesterin  in  addition  to  the  characteristic 
booklets  on  microscopic  examination.  Small  shreds  of  the  typic  laminated 
membrane  as  well  as  scolices  may  also  be  found. 

Ovarian  Cysts. — ^The  obtained  fluid  is  viscid  in  character,  varies  greatly 
in  specific  gravity  as  well  as  in  amount  of  albumin  present,  and  should 
respond  to  tests  for  metalbumin.  The  coagulable  albumin  is  removed  and 
the  fluid  filtered,  when  the  addition  of  alcohol  should  result  in  a  flocculent 
precipitate.  Microscopically  the  specimens  present  red  and  white  blood-cells, 
and  occasionally  cholesterin  crystals  and  fatty  granules.  Cylindric  ciliated 
epithelial  cells  from  the  lining  membrane  and  colloid  concretions  are  charac- 
teristic, but  unfortunately  not  always  present.  The  fluid  obtained  from 
cystic  uterine  tumors  has  a  low  specific  gravity,  is  not  viscid,  and  coagulates 
quickly,  while  that  from  parovarian  cysts  has  much  the  same  appearance 
but  does  not  coagulate. 

Hydronephrosis. — The  differential  diagnosis  of  fluid  aspirated  from  an 
ovarian  cyst  and  that  aspirated  from  a  hydronephrosis  usually  offers  no  diffi- 
culty. The  latter  is  quite  watery  instead  of  viscid,  contains  little  if  any 
albumin,  and  notable  amounts  of  urea  and  uric  acid  can  be  demonstrated. 
While  the  microscopic  examination  ma}^  be  unsatisfactor}^,  it  frequently 
presents  undoubted  renal  elements. 

Hepatic  Abscess. — In  the  microscopic  examination  of  pus  from  this  source 
a  search  for  Amelia  coli  should  not  be  neglected.  The  reminder  that  amebas 
are  the  cause  of  abscesses  in  other  parts  of  the  body  may  not  be  amiss. 

Lumbar  Puncture. — The  increased  value  of  this  procedure  as  a  diagnostic 
factor  is  noteworthy.     The  chemic  and  bacteriologic  examinations  of  the  cere- 


EXAMINATION  OF  ASPIRATED  FLUIDS  279 

bvospinal  fluid  arc  decidedly  useful,  and  cytodiagnosis,  while  still  a  disputed 
sul)ject,  promises  some  aitl.  'i'lie  normal  fluid  is  perfectly  clear  and  colorless, 
has  a  specific  gi-avity  of  about  1006,  and  contains  approximately  by  weight  1 
per  mille  of  albumin.  As  the  subject  really  belongs  to  general  medicine  rather 
than  to  surgery,  with  one  exception  the  details  have  no  place  here.  In  apo- 
plex_v,  and  injiu'ies  of  the  skull  extending  through  the  dura  mater,  the  blood 
may  make  its  way  into  the  lateral  ventricles  and  appear  on  lumbar  puncture, 
while  extradural  head  injuries  never  present  bloody  cerebrospinal  fluid. 


SECTION  VIII 
SURGICAL  OPERATIONS  IN  GENERAL 

GENERAL  CONSIDERATIONS 

Eveiy  surgical  procedure  is  productive  of  more  or  less  risk  to  the  life  of  the 
patient,  and  no  operation  should  be  entered  upon  without  clue  consideration 
of  the  dangers  which  it  entails,  as  far  as  the  patient  is  concerned,  to  say  nothing 
of  the  influence  which  the  operation  may  have  on  the  art  of  surgery  itself  or  on 
the  surgeon's  reputation.  Bearing  this  in  mind,  the  surgeon  will  carefully 
weigh  the  benefits  to  be  derived  from  the  operation  against  the  risks  to  be 
taken  in  order  to  secure  these  benefits,  and  he  will  see  to  it  that  a  life  is  not 
unnecessarily  placed  in  peril,  or  that  unjustifiable  risks  are  not  taken,  even  at 
the  patient's  own  request,  for  the  correction  of  trifling  conditions.  On  the 
other  hand,  the  practitioner  who  hesitates,  in  the  face  of  grave  surgical  emer- 
gency, to  assume  the  responsibility  which  the  circumstances  demand,  and  to 
act  promptly,  as  far  as  he  is  able,  in  order  to  saA^e  a  life,  will  bring  reproach  on 
himself  and  opprobrium  on  his  profession. 

For  purposes  of  consideration  from  the  present  standpoint  surgical  opera- 
tions maybe  divided  into  (1)  imperative  operations;  (2)  operations  of  necessity; 
(3)  oi^erations  of  utihty;  (4)  operations  of  expediency;  (5)  multiple  operations; 
(6)  unjustifiable  operations. 

Imperative  Operations. — In  this  class  may  be  placed  those  operations  that 
are  universally  acknowledged  as  of  urgent  and  immediate  necessity,  and  in 
which  the  life-saving  character  of  the  procedure  depends  on  the  promptness  of 
the  execution. 

As  instances  in  this  connection  may  be  cited  the  folloAving:  abdominal 
section  for  gunshot  and  stab  wounds  involving  the  integi'ity  of  the  intestinal 
canal  or  causing  concealed  hemorrhage;  the  ligation  of  arteries  not  accessible 
for  the  provisional  .arrest  of  hemorrhage;  amputation  for  the  removal  of  an 
extensively  mangled  and  useless  limb  in  which  crushed  nerve-trunks  tend  to 
increase  shock,  as  well  as  amputation  for  the  arrest  of  hemorrhage. 

Operations  of  Necessity. — In  this  class  may  be  mentioned  those  operations 
for  the  removal  of  malignant  grow^ths  and  other  neoplasms,  as  well  as  for  con- 
ditions which,  though  urgently  demanding  surgical  interference,  permit  time 
and  opportunity  for  due  preparation. 

Operations  of  Utility. — In  this  class  of  cases  an  effort  is  made  to  correct 
conditions  which  tend  to  prevent  the  patient  from  entering  into  the  ordinary 
pursuits  and  enjoyments  of  life,  even  if  they  do  not  threaten  or  shorten  his 
existence.  As  familiar  instances  of  this  class  of  operations  may  be  noted 
plastic  procedures  for  harelip  and  cleft  palate;  tenotomies  and  bone  resections 
for  clubfoot;  operations  designed  to  correct  deformities  which  are  the  result 
of  paralyses  and  contractures  arising  from  diseases  of  the  central  nervous 

280 


COMMON    DANGERS  OF   SURGICAL   OPERATIONS  281 

system,  as  well  as  those  due  to  injury;  operations  for  the  permanent  fixation  of 
Ihiil  joints  (see  Arthrodesis,  page  372);  tendoplasty  for  transferring  a  portion 
of  the  muscular  force  from  active  to  paralyzed  parts. 

Operations  of  Expediency. — These  are  the  so-called  cosmetic  operations, 
and  are  usually  designed,  as  the  name  implies,  to  improve  some  unsightliness  in 
the  personal  appearance  of  the  patient.  An  instance  of  a  purely  cosmetic 
operation  is  that  for  projecting  or  protuberant  ears.  Certain  operations  in  this 
class,  while  they  are  performed  primarily  for  cosmetic  purposes,  yet  serve  a 
further  and  useful  end,  c.  g.,  the  operation  for  ectropion  of  the  eyelid,  in  which, 
in  addition  to  the  improvement  of  the  patient's  appearance,  there  is  a  restora- 
tion of  the  protective  function  of  this  structure  to  the  globe. 

Multiple  Operations. — Operations  on  the  pelvic  floor  of  women  who 
have  borne  children  come  more  particularly  under  this  head.  In  the 
majority  of  cases  of  parturient  injuries  the  conditions  demand  for  their  relief 
several  independent  operative  procedures,  particularly  if  these  are  performed 
some  time  after  delivery.  These  include  curettage  of  the  uterus  for  the  chronic 
endometritis  which  is  commonly  present,  trachelorrhaphy  for  the  lacerated 
cervix  uteri,  and  perineorrhaphy.  In  more  aggravated  cases,  or  those  of  long 
standing,  anterior  and  posterior  colporrhaphy  may  be  necessary.  Further, 
prolapse  and  retrodeviation  of  the  uterus,  as  well  as  infections  of  the  adnexa, 
may  be  present  and  demand  hysterorrhaphy  for  the  first  named  and  oopho- 
rectomy' and  salpingectomy  for  the  second.  Finally,  the  presence  of  aggravated 
hemorrhoids  is  not  uncommon  in  this  class  of  cases.  All  of  the  above  operations 
may  be  necessary  in  the  same  patient,  and  it  becomes  a  question  of  judgment 
in  each  individual  case  as  to  how  many  and  which  of  them  shall  be  performed 
at  one  sitting. 

Whenever  several  operations  are  performed  on  a  patient  at  the  same 
seance,  care  should  be  observed  to  conduct  the  several  procedures  in  the  order 
of  their  cleanliness.  For  instance,  an  operation  for  hemorrhoids  should  not 
precede  an  abdominal  section.  This  rule  does  not  always  hold  good,  however. 
If  a  peritoneal  suspension  of  the  uterus  or  a  salpingo-oophorectomy  precedes  a 
trachelorrhaphy,  dragging  on  the  uterus  in  the  performance  of  the  latter  may 
nullify  the  hysterorrhaphy,  or,  in  the  case  of  the  adnexal  operation,  cause  the 
slipping  of  a  ligature  and  the  occurrence  of  concealed  hemorrhage. 

Unjustifiable  Operations. — No  self-respecting  surgeon  will  perform  an 
operation  for  the  removal  of  healthy  ovaries,  the  ligation  of  the  Fallopian  tubes, 
and  similar  procedures  intended  to  prevent  conception  in  a  woman  capable  of 
bearing  children;  nor  will  he  perform  an  operation  designed  to  alter  the  per- 
sonal appearance  of  an  individual  for  the  purpose  of  disguise  or  to  enable 
him  to  escape  punishment  for  crime. 


COMMON  DANGERS  OF  SURGICAL  OPERATIONS 

Excessive  fear  is  to  be  mentioned  in  this  connection.  That  the  mental 
condition  bears  some  relation  to  the  occurrence  of  shock  there  can  be  no  doubt, 
since  it  has  been  shown  that  stoically  inclined  individuals,  and  those  hopefully 
inclined,  as  well  as  children  and  the  insane,  other  things  being  equal,  suffer 
comparatively  little  from  shock. 


282  SURGICAL  OPERATIONS  IX  GENERAL 

The  administration  of  a  general  anesthetic  gives  rise  to  certain  imme- 
diate and  well-defined  risks,  which  should  always  be  taken  into  account  in 
this  connection.  These  relate  particularly  to  the  effects  of  the  anesthetic  agent 
on  the  heart  and  respiratory  apparatus,  as  well  as  to  the  dangers  arising  from 
mechanic  causes,  such  as  jaw  spasm  with  the  forcing  back  of  the  tongue  so  as  to 
obstruct  the  glottic  opening,  which  occurs  in  the  case  of  ether  anesthetization 
particularly,  and  the  lodgment  of  foreign  bodies,  as  false  teeth,  chewing- 
gum,  vomited  matter,  etc.,  in  the  respiratory  passages.  Violent  struggUng  on 
the  part  of  the  patient  at  the  commencement  of  chloroform  anesthetization 
leads  to  a  most  pronounced  and  rapid  effect  of  the  drug,  and  if  its  administration 
is  persisted  in  under  these  circumstances,  it  may  cause  fatal  narcosis.  Want 
of  proper  care  and  watchfulness  on  the  part  of  the  anesthetist  may  also  easily 
permit  the  latter  to  occur. 

The  avoidance  of  hemorrhage  constitutes  the  most  imperative  duty  of 
the  operating  surgeon.  The  careful  and  systematic  clamping  of  each  ordinary 
sized  bleeding  vessel  as  it  is  encountered,  prompt  finger  pressure,  and  a  properly 
directed  effort  to  secure  the  bleeding  point  in  the  case  of  injury  to  a  larger 
branch  or  main  trunk  form  a  very  important  part  of  the  training  of  the  skilled 
operator.  While  the  loss  of  some  blood  is  unavoidable  during  an  operation, 
the  aim  should  be  to  minimize  this  loss  as  much  as  possible  consistent  with  the 
proper  conduct  of  the  operation,  since,  without  due  regard  to  this  rule,  the 
dangers  from  shock  are  greatly  increased  and  the  healing  process  is  retarded. 
A  considerable  loss  of  blood  extending  over  a  longer  period  of  time  is  better 
borne  by  the  patient  than  the  same  cjuantity  escaping  by  a  sudden  gush  from 
a  large  trunk.  Failure  to  institute  prompt  measures  to  compensate  for  the 
loss  of  blood  when  this  is  excessive  may  sacrifice  the  patient's  life,  even  after 
arrest  of  bleeding  is  promptly  and  properly  secured.  The  dangers  of  hemor- 
rhage do  not  cease  with  the  completion  of  the  operation;  the  patient  must  be 
watched  for  subsequent  bleeding  up  to  the  time  when  definite  healing  of  the 
ligated  vessels  may  be  expected  to  occur  (see  page  88). 

Shock. — This  term  is  used  to  designate  an  extreme  functional  depression, 
first,  of  the  nervous  system,  and,  second,  in  consec^uence  of  the  first,  of 
the  circulatory  system,  resulting  from  an  injury  or  occurring  as  one  of  the 
effects  of  an  operation.  Young  children,  the  aged,  and  weak  individuals 
suffer  most  from  shock.  Children,  however,  recover  most  readily  from  its  effects. 
Excessive  weakness  of  the  heart's  action  is  the  predominating  feature  in  shock. 
The  symptoms  of  shock  and  excessive  loss  of  blood  combined,  as  they  some- 
times are,  with  the  effects  of  over  or  prolonged  anesthetization,  make  up  a 
clinical  picture  of  a  patient  critically  ill  from  the  effects  of  an  operation. 

If  a  patient  is  suffering  from  shock  as  the  result  of  an  injury,  none  but  the 
most  imperatively  demanded  operations,  such,  for  instance,  as  that  recjuired 
for  the  arrest  of  hemorrhage,  or  for  the  relief  of  some  condition  on  which  the 
continuance  of  the  shock  depends,  should  be  undertaken.  If  shock  comes  on 
in  the  course  of  an  operation,  the  latter  should  be  concluded  as  c|uickly  as  pos- 
sible; in  some  instances  it  will  be  necessary  to  suspend  it  entirely. 

When  the  patient  once  rallies  from  shock,  the  improvement  is  continuous, 
and  in  some  instances  rapid.  The  terms  "  delayed  shock,"  "  secondary  shock," 
and  "imperfect  reaction  from  shock"  are  misleading,  and  relate  to  conditions 
arising  independently  of  the  original  shock,  such  as  concealed  hemorrhage 


SPECIAL    DANGERS    OF    OPERATIONS  283 

(see  page  89),  rapitlly  developing  and  virulent  septic  infection,  fat  embolism, 
pulmonary  edema,  renal  insufficiency,  etc. 

Shock  may  be  (|iiickly  recovered  from  if  no  vital  organ  is  seriously  involved 
in  the  injury  or  operation,  or  if  the  source  of  the  depression  is  not  persistent 
and  continuous,  such,  for  instance,  as  the  presence  of  a  mangled  limb  with 
crushed  nerve-trunks,  etc.  In  fatal  cases  the  temperature  becomes  subnormal 
and  death  takes  place  from  combined  cardiac  and  respiratory  failure. 

In  the  prevention  of  shock  the  patient's  mental  condition  should  be  taken 
into  account,  antl,  as  a  part  of  the  preparation  for  the  operation,  every 
encouragement  given  him  as  to  its  outcome.  Nervous  patients  are  benefited 
b}'  a  few  days'  preliminary  rest  in  bed.  Opiates  and  bromids  may  be  given 
as  indicated.  A  oV-grain  dose  of  strychnin  may  be  given  after  anesthetization, 
if  indicated.  During  the  operation  the  patient  should  be  kept  warm,  and,  in 
long  operations,  artificial  heat  should  be  applied.  Loss  of  blood  must  be 
avoided  and  operations  brought  to  a  close  as  quickly  as  possible. 

The  preliminary  injection  of  cocain  into  a  nerve-trunk  of  a  part  operated 
on  inhibits  the  transmission  of  afferent  and  efferent  impulses  and  tends  to 
lessen  operative  shock  (C  r  i  1  e). 

Treatment  of  Shock. — The  patient's  head  is  to  be  lowered,  and  artificial 
heat  applied  to  the  whole  body  by  means  of  hot-water  bags,  or,  better  still,  the 
patient  may  be  wrapped  in  blankets  wrung  out  of  hot  water.  An  intravenous 
infusion  of  from  800  to  1200  c.c.  of  saline  solution  (1  dram  of  common  table  salt 
to  a  pint  of  sterilized  water  at  115°  to  120°  F.)  should  be  given.  Pending 
preparations  for  this,  the  saline  solution  is  to  be  injected  into  the  loose  connec- 
tive tissue  behind  the  breasts  (see  Hypodermoclysis,  page  352).  High  enemas 
consisting  of  a  quart  of  hot  saline  solution,  3  ounces  of  black  coffee,  and  2 
drams  of  whisky  should  be  given.  Strychnin  should  be  administered  carefully 
(not  more  than  two  ^Vgrain  doses).  Oxj^gen  is  to  be  administered.  Nitro- 
glycerin and  amyl  nitrite  are  contraindicated  in  shock  on  account  of  the 
vasomotor  dilatation  which  they  induce.  Ergot,  on  the  other  hand,  is  said  to 
possess  distinct  value  in  this  connection.  I  have  employed  it  with  apparent 
advantage.  It  is  to  be  given  hypodermically  in  the  shape  of  either  ergotol  in 
30-minim  doses  repeated  every  half  hour,  or  solutions  of  the  aqueous  extract. 

SPECIAL  DANGERS  OF  OPERATIONS 

These  relate  chiefly  to  the  locality  in  which  the  operation  is  performed  and 
its  proximity  to  certain  important  nerve-trunks  and  large  vessels.  Prolonged 
operations  on  the  intracranial  contents^  or  in  the  area  of  important  and 
extensively  distributed  sensory  nerves,  such,  for  instance,  as  the  fifth  or  tri- 
facial nerve,  either  b}^  direct  means  or  by  reflex  inhibitory  effects,  greatly 
augment  the  dangerous  effects  of  shock. 

The  entrance  of  air  into  veins,  though  a  rare  circumstance,  is  an 
accident  against  which  the  surgeon  should  be  on  his  guard,  particularly  when 
operating  in  the  lateral  region  of  the  neck.  In  the  event  of  a  wound  of  a  large 
A'ein  in  this  locality  the  opening  in  the  vessel  is  kept  patent  by  the  cervical 
fascia,  while  the  vacuum  produced  by  the  inspiratory  effort  causes  the  air  to 
rush  in.  The  accident  has  occurred  most  frequently  in  connection  with  the 
internal  and  external  jugular  veins  and  the  subclavian.     It  has  happened. 


284  SURGICAL   OPERATIONS   IN    GENERAL 

however,  in  the  case  of  the  cerebral  sinuses,  and  the  facial,  axillary,  sub- 
scapular, thoracic,  and  femoral  veins  (for  Air  Embohsm  see  page  98). 

The  dangers  of  hemorrhage  are  enhanced  when  the  operation  is  con- 
ducted in  the  neigh])orhood  of  the  large  vessels.  These  dangers  arise,  not 
only  from  the  risks  of  wounding  the  main  trunk,  but  from  the  fact  that  wounded 
branches  bleed  more  freely  under  these  circumstances  and  a  large  amount  of 
blood  is  lost  in  a  short  time. 

Patients  with  hemophilia  ("bleeders")  are  the  most  unpromising  of  all 
subjects  for  operation.  Scarcel}'  anything  has  been  brought  to  light  concerning 
the  pathology  of  the  disease  and  almost  as  little  success  has  attended  efforts  to 
cope  with  the  bleeding  which  occurs  in  its  victims.  This  may  result  from  the 
most  trivial  injury  and  may  be  initiated  by  a  diseased  condition,  such,  for 
instance,  as  occurred  in  a  patient  under  my  care  in  the  German  Hospital,  in 
whom  the  ruptured  vessels  at  the  site  of  a  perforation  of  the  vermiform  ap- 
pendix gave  rise  to  a  hemophilic  bleeding,  which  all  efforts,  including  exposure 
of  the  source  of  the  hemorrhage  and  topical  pressure,  failed  to  arrest.  In  the 
treatment  of  hemorrhage  in  a  hemophiliac  where  direct  pressure  can  be  made, 
this  offers  the  best  chance  of  arresting  the  bleeding.  In  addition,  the  common 
styptics,  adrenalin  chlorid  solution  (1  :  1000)  by  subcutaneous  and  intra- 
venous injection,  heat,  cold,  the  actual  cautery,  the  rectal  administration  of 
gelatin  solutions  (5  per  cent),  and  the  internal  administration  of  chlorid 
of  calcium  and  ergot  should  be  tried. 


POST-OPERATIVE  COMPLICATIONS 

The  most  important  immediate  post-operative  complications  are  the  fol- 
lowing : 

Excessive  Retching. — This  may  become  a  source  of  anxiety  on  account 
of  the  possibility  of  cerebral  hemorrhage  due  to  the  straining  efforts  in 
patients  with  atheromatous  vessels.  Lavage  with  saline  solution  is  of  service. 
It  sometimes  becomes  necessary  to  administer  a  hypodermic  injection  of 
morphin  to  quiet  the  reflex  disturbances. 

Recurring  hemorrhage  from  the  slipping  of  a  ligature,  or  from  a 
vessel  which  was  injured  near  the  close  of  the  operation  and  w^hich  failed  of 
ligation,  is  an  occasional  complication  at  this  stage  (see  Treatment  of  Hemor- 
rhage, page  336). 

More  or  less  complete  suppression  of  urine  (anuria)  and  disten- 
tion of  the  bladder  from  retention  of  urine  are  to  be  guarded  against. 
Fluids  given  freely  to  drink,  saline  irrigation  of  the  rectum,  copious  enemas  of 
saline  solution,  dry  cupping  of  the  renal  region  to  relieve  the  congestion  of  the 
kidneys  on  which  the  suppression  depends,  and,  if  this  fails,  wet  cupping  of  the 
same,  hypodermoclysis,  and,  finally,  intravenous  saline  infusion,  are  the 
measures  to  be  resorted  to  in  cases  of  anuria;  in  cases  of  retention  careful 
catheterization  should  be  performed. 

Acute  Post=operative  Dilatation  of  the  Stomach. — This  has  been 
observed  as  the  result  of  a  more  or  less  complete  prolapse  of  the  small 
intestine  into  the  lesser  pelvis.  The  pressure  of  the  mesentery,  particularly  of 
the  superior  mesenteric  artery,  thus  arising  causes  compression  and  obstruction 


POST-OP KUATIVl':    CO.MPLICATK^N.S  285 

of  the  iluoilcnmu,  Avilli  con.scHiuciiL  dilatation  of  the  latter  and  finally  of  the 
stomach  as  well.  The  predisposing  causes  are  said  to  be  the  weakening  effects 
of  general  anesthetization  and  too  co])ions  purgation  preceding  the  ojjeration. 
The  condition  can  occur  only  with  the  patient  in  the  dorsal  i)osition. 

The  symptom  dominating  the  clinical  picture  of  this  post-operative  com- 
plication is  \()niiting,  which  is  often  very  abundant  and  persistent,  and  usually 
biliary;  more  rarely  brownish-gray  or  blackish.  Intractable  constipation 
is  usually  present;  flatus  is  generally  obstructed;  thirst  is  urgent;  the  pulse 
is  increased  in  freciuency;  the  temperature  remains  normal.  The  patient's 
appearance  is  that  of  one  critically  ill.  The  diagnosis  is  confirmed  by  the 
demonstrable  ]:)resence  of  gastric  dilatation. 

The  treatment  consists  in  placing  the  patient  in  the  al)dominal  position 
(flat  on  the  abdomen)  at  once  upon  the  appearance  of  symptoms  of  duodenal 
compression  (jM  u  1 1  e  r).     Lavage  may  also  be  practised. 

The  more  remote  complications  include  delirium  tremens,  sepsis,  peritoni- 
tis, tympanites,  and  pneumonia. 

Delirium 'tremens  is  a  form  of  mental  disturl^ance  in  which  muscu- 
lar tremors  are  a  characteristic  feature.  It  occurs  in  persons  habitually 
intemperate  in  the  use  of  alcohol.  It  may  follow^  an  operation  or  any  form  of 
injury.  The  type  of  the  disease  is  milder,  as  a  rule,  than  that  which  develops 
Avithout  injury.  The  attack  is  sometimes  preceded  by  restlessness  and  tremu- 
lousness,  and  is  ushered  in  by  insomnia  and  delusions  of  persecution  and  of  the 
presence  of  reptiles,  animals,  and  insects  which  inspire  fear  and  horror.  If  the 
patient  is  not  restrained,  he  wifl  attempt  to  escape  from  these  by  flight,  entirely 
insensible  to  the  pain  of  an  injury  or  of  the  part  operated  on.  In  some  cases 
there  is  marked  and  rapid  loss  of  strength.  The  attack  may  pass  off  suddenly 
after  a  long  sleep.  Death  may  take  place  from  prostration  or  suddenly  from 
heart  failure. 

The  treatment  of  delirium  tremens  consists  in  warding  off  an  impending 
attack  by  means  of  stimulants  in  small  quantities,  and  the  administration  of 
capsicum  and  digitalis.  Sleep  should  be  secured  by  chloral  hydrate  and  the 
bromids.  During  the  attack  the  patient  should  be  protected  from  doing  him- 
self harm  by  a  restraint  sheet  and  wristlets.  Malt  liquors  should  be  given  ad 
libitum.  Opium  should  be  reserved  for  cases  in  which  restraint  to  the  extent  of 
preventing  displacement  of  splints  or  dressings  is  difficult  or  impossible. 

Septic  inflammation  is  the  most  important  of  the  post-operative 
sequels,  and  its  advent  should  be  most  carefully  watched  for  by  a  frequent 
inspection  of  the  temperature  record.  If  it  occurs,  its  further  progress  should 
be  guarded  against  by  thorough  disinfection  of  the  wound,  the  sutures  being 
remoA-ed  for  this  purpose,  if  necessary  (see  page  58).  In  abdominal  cases  the 
surgeon  will  be  on  his  guard  particularly  against  the  occurrence  of  peritonitis. 
Tympanitic  distention  is  sometimes  the  cause  of  considerable  discomfort  and 
will  require  for  its  relief  either  the  use  of  the  rectal  tube  or  enemas  containing 
turpentin  or  lac  asafetida. 

Post=operative  pneumonia  may  be  the  result  of  exposure  of  the  patient 
while  under  the  anesthetic,  either  when  he  is  on  the  operating  table  or  subse- 
quently. It  has  likewise  been  attributed  to  the  refrigerant  action  of  the  ether 
when  this  has  been  employed  as  the  anesthetic  agent.  In  the  hypostatic  form 
it  arises  from  keeping  the  patient  constantly  in  the  dorsal  decubitus.     Septic 


286  SURGICAL    OPERATIONS   IX    GENERAL 

pneumonia  results  from  the  inspiration  of  septic  agents  during  the  anesthetiza- 
tion, and  from  the  passage  of  septic  material  into  the  air-passages  from  the 
nasal,  nasopharyngeal,  and  buccal  cavities  after  operations  in  these  regions. 
In  the  latter  case  it  may  be  followed  Vjy  gangrene  of  the  lung.  Prophylaxis 
consists  in  (1)  employing  due  care  not  to  expose  the  patient  unnecessarily 
while  under  the  anesthetic;  (2)  keeping  the  patient's  head  turned  to  one  side 
during  the  anesthetization  in  order  to  favor  the  accumulation  of  mucus,  etc., 
in  one  or  the  other  of  the  lateral  portions  of  the  pharynx,  whence  it  may  be 
readil}"  removed  by  a  strip  of  gauze  leading  out  of  the  corresponding  corner  of 
the  mouth,  or  by  sponging;  (3)  taking  measures  to  establish  and  maintain 
aseptic  conditions  of  the  parts  after  operations  on  the  mouth,  throat,  and  nose 
(see  page  49);  (4)  alternating  the  position  of  the  patient  during  convalescence 
between  the  lateral  and  the  dorsal. 

The  treatment  of  post-operative  pneumonia  embraces  dry  cupping,  a 
pneumonia  jacket  (oiled  silk  lined  with  cotton  batting),  and  systematic  change 
of  decubitus.  Ten-grain  doses  of  carbonate  of  ammonia  in  half  an  ounce  of 
equal  parts  of  mucilage  of  acacia,  spearmint  water,  and  syrup,  given  every 
two  hoirrs,  alternated  with  10-grain  doses  of  chlorid  of  calcium,  are  of  service. 
(For  Gangrene  of  the  Lung,  see  page  682.) 

Causes  of  Death  Following  Surgical  Operations. — Death  following 
a  surgical  operation  may  arise  from  hemorrhage,  from  shock,  or  from 
these  two  combined;  or  from  these  with  the  addition  of  prolonged  or  too 
profound  narcosis;  or  from  entrance  of  air  into  the  veins;  or  from  overstimu- 
lation of  the  heart  arising  from  the  absorption  of  several  doses  of  drugs  at  once 
administered  hypodermically  during  shock.  During  and  after  anesthetization 
the  foundation  may  be  laid  for  a  fatal  post-operative  pneumonia  {vide  supra). 
Suffocation  arising  from  inspiration  of  vomited  matters  while  the  patient  is  still 
unconscious  may  prove  fatal.  Death  may  occur  from  acute  dilatation  of  the 
stomach  (vide  supra).  Uremia  following  anuria  in  those  with  diseased  kidneys 
may  destroy  the  patient.  Infections  from  pus  organisms  may  give  rise  to  lethal 
pyemia  and  septicopyemia  (see  pages  182  and  184;.  The  special  infection  of 
tetanus  is  quite  uniformly  fatal.  Delirium  tremens  following  a  long  debauch 
may  be  fatal.  Death  may  be  due  to  some  organic  disease  of  a  vital  organ; 
to  pulmonary  thrombosis;  to  extension  of  infection  and  complicating  inflam- 
mations of  newly  involved  tissues  or  organs;  to  perforative  peritonitis  resulting 
from  rough  handling  of  the  intestines;  to  post-operative  peritonitis  due  to 
imperfect  asepsis;  to  intestinal  obstruction  caused  by  angulation  at  the  site  of 
adhesions  following  an  abdominal  section;  or  to  senile  asthenia  aggravated 
by  surgical  interference  in  those  both  aged  and  infirm. 

Acute  cardiac  dilatation  may  cause  death  in  a  totally  unexpected  manner, 
and  at  a  period  so  remote  from  the  operation  as  to  arouse  some  doubt  as  to  the 
connection  between  the  two.  In  six  cases  occurring  in  my  experience  death 
took  place  at  periods  varying  from  ten  to  sixteen  days  after  the  operation. 
The  latter  had  been  succeeded  by  an  absolutely  uneventful  course  up  to  the 
occurrence  of  the  acute  dilatation.  In  none  of  the  cases  had  a  heart  lesion  been 
made  out  before  the  operation.  In  three  of  the  cases  the  patients  were  awak- 
ened from  sleep  by  the  faint  sensation  which,  in  two  of  the  cases,  preceded 
death  by  less  than  a  minute.  It  is  estimated  that  in  none  of  the  six  cases 
did  the  patient  live  longer  than  a  minute  after  the  first  symptom.     In  tho.se 


POST-OPERATIVE   COMPLICATIONS  287 

attacks  which  occurred  while  the  patient  was  awake  the  first  impulse  was  to 
ask  for  a  drink  of  water,  but  before  this  could  be  given  the  jjatient's  alarming 
aijpearance.  attracted  attention  to  the  pulse,  which  was  found  to  be  weak 
and  fluttering.* 

*  The  following  is  a  sumniarv  of  the  cases:  one  case  of  amputation  of  the  shoulder- 
joint;  death  on  the  sixteenth  day  after  operation  and  after  complete  healing;  the  patient 
was  being  con\eyed  home  in  a  carriage  when  attacked.  One  case  of  abdominal  hysterec- 
tomy; death  on  the  eleventh  day  while  the  patient  was  uneventfully  reco^•ering  from  the 
operation.  Two  cases  of  appendectomy;  death  in  the  one  case  on  the  eleventh  day  and 
in  the  other  on  the  fifteenth  day.  In  the  first  case  the  patient  died  while  on  the  Ijedpan; 
in  the  other  case  the  patient  was  awakened  from  sleep  by  the  faint,  sinking  sensation.  One 
case  of  operation  for  radical  cure  of  hernia;  patient  attacked  on  the  fourteenth  day  in 
the  night  and  had  time  only  to  whisper  faintly  a  message  for  his  family  when  he  breathed 
his  last.  One  case  of  nephrolithiasis  which  had  gone  on  to  the  thirteenth  day  without 
the  slightest  deviation  from  the  normal,  after  the  recovery  from  the  anesthetic:  the 
patient  asked  the  nurse  for  a  glass  of  water  in  a  faint  whisper,  and  died  before  it  could  be 
handed  to  her.  The  youngest  patient  was  thirty-two,  the  oldest  was  se^-enty.  In  all  of 
the  cases  there  was  the  predominating  feature  of  an  absolutely  uncomplicated  and  ap- 
parently safely  established  convalescence  up  to  less  than  two  minutes  before  the  patient's 
death.  In  the  three  cases  in  which  autopsy  was  permitted  the  left  ventricle  was  found 
somewhat  thinner  than  the  average  normal  ventricle;  the  heart's  action  had  been  arrested 
in  ventricular  diastole:  the  remaining  portions  of  the  organ,  as  well  as  all  the  other 
organs  of  the  body,  were  found  to  be  in  a  healthy  state. 


SECTION  IX 
SURGICAL  ANESTHESIA 

Surgical  anesthesia  is  of  two  kinds,  general  and  local.  The  first  named  is 
sometimes  called  narcosis. 

For  ordinary  surgical  purposes  general  anesthesia  must  be  produced.  The 
ideal  production  of  general  anesthesia  without  narcosis  has  yet  to  be  reached. 

The  indications  for  the  use  of  anesthetics  are  various.  The  suscepti- 
bility of  the  individual  to  pain,  the  length  of  time  the  proposed  operation  is  to 
occupy,  the  amount  of  pain,  the  necessity  for  restraining  the  patient's  move- 
ments during  the  operation,  must  all  be  taken  into  account.  Some  operations 
may  be  quite  prolonged  and  yet  comparatively  fi-ee  from  pain;  hence  continu- 
ous and  prolonged  anesthesia  is  not  rec^uired.  Again,  an  operation  may  give 
rise  to  the  most  exquisite  pain  and  yet  be  of  such  short  duration  as  scarcely  to 
justify  the  employment  of  a  general  anesthetic.  Were  it  not  for  the  fact  that 
there  is  a  lurking  danger  attendant  on  every  occasion  where  an  anesthetic 
is  employed,  anesthesia  could  be  induced  with  propriety  for  all  operations, 
including  those  causing  even  the  slightest  pain. 

Surgical  anesthesia  is  also  induced  for  the  purpose  of  producing  relaxation 
of  muscular  structures,  as,  for  instance,  in  the  reduction  of  dislocations  and  for 
the  adjustment  of  the  displaced  fragments  in  fractures.  Finally,  it  is  almost 
impossible  to  make  a  diagnosis  m  some  cases  without  the  aid  of  anesthesia. 

The  Physiologic  Action  of  Ether  and  Chloroform. — The  anesthesia 
obtained  by  the  use  of  these  agents  results  from  the  direct  influence  of 
the  drug  on  the  nervous  system,  as  shown  b}'  Bernstein's  experiments 
on  frogs.  The  frogs  were  successfully  chloroformed  after  the  aorta  had  been 
severed,  all  blood  withdra-wm  and  its  place  supplied  by  sodium  chlorid  solution. 

Further  experiments  by  Bernstein  demonstrated  that  portions  of  the 
central  nerv^ous  system  excluded  from  the  circulation  are  not  influenced  by  the 
anesthetic,  as  sho^\Ti  by  the  fact  that  under  these  circumstances  the  peripheral 
portions  supplied  by  these  centers  do  not  lose  their  reflex  irritability.  In 
another  experiment  the  femoral  arterv^  was  ligated,  after  which  it  was  found  that 
both  limbs  alike  were  affected  by  the  influence  of  the  anesthetic. 

Early  in  the  administration  of  ether  there  is  a  cardiac  and  a  vasomotor 
stimulation;  later  this  is  followed  by  depression  and  fall  of  blood-pressure. 

The  action  of  chloroform  on  the  heart  is  as  follows :  it  acts  directlj'  on  the 
heart  muscle,  steadily  and  strongly  depressing  and  paralyzing  it  or  its  contained 
ganglia;  to  this  depression  is  due  the  early  fall  of  blood-pressure  occurring 
in  chloroform  narcosis. 

While  the  pupil  may  become  temporarily  dilated  slightly  beyond  the  normal 
during  the  early  stages,  it  becomes  contracted  below  the  normal  as  the  anes- 
thesia advances.  A  return  to  the  normal  requires  that  more  of  the  anesthetic  be 
administered,  but  a  sudden  dilatation  imperatively  demands  its  immediate 
withdrawal. 

288 


THK   Sia.KCTIOX   OF   AN   ANKSTHKTIC  289 

The  Selection  of  an  Anesthetic. — The  anesthetic  agents  usually  em- 
ployed at  the  present  day  are  nitrous  oxid,  ether,  and  chloroform.  These  should 
be  obtained  in  as  pure  a  state  as  possible.  Tests  are  given  for  ascertaining 
tlieir  purity,  but  ])ractically  the  surgeon  is  at  the  mercy  of  the  manufacturer, 
and  should  thei'(^fore  supph'  himself  from  one  of  standing  and  reputation. 

Nitrous  oxid  is  the  safest  general  anesthetic  at  present  known.  In  ex- 
perienced hands  its  use  is  practically  without  risk.  Any  danger  that  may 
attend  its  use  in  unskilled  hands  is  eliminated  l)y  administering  it  with  oxygen. 
Under  these  circumstances  the  dangers  are  but  infinitesimal.  Unfortunately, 
nitrous  oxid  is  both  inconvenient  and  inapplicable  for  most  surgical  operations, 
though  it  may  be  employed  for  those  of  short  duration. 

Sulfuric  Ether. — Of  the  anesthetic  agents  suitable  for  prolonged  adminis- 
tration ether  is  the  safest,  and,  unless  directly  contraindicated,  should  be 
invariably  employed.  Its  great  advantage  is  the  stimulating  effect  which  it 
produces  on  the  circulation.  Even  the  sitting  posture  is  not  liable  to  result  in 
circulatory  respiratory  depression  while  the  patient  is  under  its  influence.  It 
shoukl  therefore  be  the  routine  anesthetic  for  general  surgical  work. 

The  contraindications  for  the  use  of  ether  are  extreme  emphysema, 
chronic  hronchitis  with  expectoration  and  dyspnea,  and  advanced  pulmonary 
phthisis.  In  the  case  of  very  old  persons  and  in  those  extremely  obese,  as  well  as 
in  very  young  children,  ether  is  not  generally  employed.  It  may,  however,  be 
employed  in  old  persons  in  whom  the  arteries  are  not  markedly  atheromatous, 
and  in  young  children,  and  even  in  infants.  In  the  case  of  the  latter,  however, 
the  open  method  should  be  used.  Though  albuminuria,  nephritis,  and  uremia 
have  been  known  to  follow  the  use  of  ether,  it  is  now  generally  believed  that 
these  sequels  may  follow,  although  perhaps  not  so  frequently,  when  chloro- 
form is  administered  in  equal  amounts,  and  that  they  do  not  follow  either 
anesthetic  as  frequently  as  is  generally  supposed  unless  renal  disease  exists 
beforehand.  It  may  be  observed,  however,  that  the  kidneys  play  a  large 
part  in  the  elimination  of  the  anesthetic  agent,  and  if  diseased,  may  fail  to 
perform  their  function,  or  become  congested  through  the  necessarily  increased 
activity  of  the  vessels,  suppression  following. 

Chloroform  is  used  in  operations  on  the  palate,  tongue,  jaws,  mouth,  nasal 
cavities,  nasopharynx  and  pharynx,  on  account  of  the  difficulties  arising  from 
attempts  to  anesthetize  the  patient  with  ether  mingled  with  a  large  amount  of 
au-.  When  the  actual  cautery  is  to  be  used  in  these  regions,  even  when  ether 
might  otherwise  be  employed,  chloroform  must  be  substituted,  on  account  of 
the  inflammability  of  the  vapor  of  the  former.  Under  all  circumstances,  how- 
ever, unless  the  use  of  ether  is  strongly  contraindicated,  anesthetization  by  this 
agent  should  be  first  obtained  and  chloroform  employed  only  during  the  actual 
performance  of  the  operation. 

In  cases  in  which  there  is  a  fixed  condition  of  the  abdominal  walls,  as,  for 
instance,  in  connection  with  general  peritonitis  from  perforation,  and  intestinal 
obstruction  with  respiratory  difficulty,  chloroform  may  be  used  preliminarily 
to  etherization. 

Finally,  when  it  is  shown  by  actual  trial  that  ether  is  badly  borne,  either 

through  uncontrollable  coughing,  embarrassed  breathing,  deep  cyanosis,  or 

prolonged  tonic  spasm,  chloroform  may  be  temporarily  substituted.     When 

the  patient  is  fully  anesthetized  by  chloroform,  however,  it  will  frequently  be 

20 


290  SURGICAL   ANESTHESIA 

found  that  these  conditions  have  disappeared  and  that  ether  may  be  admin- 
istered.    In  stenosis  of  the  larynx  and  trachea  chloroform  may  be  employed 
with  advantage,  as  it  is  less  likely  to  irritate  and  produce  spasm  of  the  glottis. 
The    Preparation    of    the    Patient    for    an    Anesthetic— It    not 

infrequently  occurs  that  the  condition  of  the  patient  is  such  as  to  prohibit 
the  employment  of  an  anesthetic.  Each  organ  should  be  carefully  examined 
beforehand,  as  far  as  possible,  but  particular  attention  should  be  paid  to  the 
heart  and  vessels,  lungs  and  kidneys.  The  digestive  organs  should  not  be 
overlooked.  The  intestinal  canal  should  be  emptied  by  a  purge  administered 
the  day  previous,  and  thereafter  only  food  allowed  which  shall  leave  the  mini- 
mum amount  of  residuum  in  the  bowels.  ^leat  broths  and  such  food  fulfil 
this  indication.  No  liquid  food  is  to  be  permitted  for  at  least  four  hours  before 
the  operation,  and  solid  food  should  be  omitted,  wherever  practicable,  for  eight 
hours  previous.  If  this  rule  has  been  transgressed,  in  emergency  cases  where 
food  has  been  recently  taken,  lavage  may  be  practised.  The  reasons  for  with- 
holding food  are  (1)  the  presence  of  food  is  provocative  of  vomitmg,  with  re- 
sulting dangers  of  inspiration  of  vomited  food;  (2)  excretion  of  ether  takes 
place  by  the  gastric  and  intestinal  mucous  membrane,  and  arrest  of  digestion 
and  the  production  and  absorption  of  toxic  products  occurs  in  consequence. 

Except  in  emergencies,  the  examination  of  the  heart  and  lungs  should 
be  made  on  the  previous  day.  The  patient  is  thereby  made  more  comfortable 
by  the  assurance  that  these  are  in  a  healthy  condition.  This  likewise  gives 
the  surgeon  an  opportunity  to  postpone  the  operation,  in  case  these  organs  are 
not  found  normal,  without  unduly  exciting  the  fears  of  the  patient.  This 
examination  should  be  made,  if  possible,  by  the  person  who  is  to  administer  the 
anesthetic.  In  emergency  cases  the  examination  may  be  made  just  before 
commencing  the  administration  of  the  anesthetic. 

The  examination  of  the  kidneys  is  most  important.  Not  only  should 
the  presence  or  absence  of  albumin  in  the  urine  be  determined,  but  tube  casts 
should  be  eliminated  as  well.  The  examination  of  the  urine  for  urea  is, 
however,  of  far  more  importance  than  the  test  for  albumin  or  even  a  micro- 
scopic examination  for  casts.  It  is  now  well  known,  in  cases  of  renal  disease, 
that  the  appearance  of  both  albumin  and  casts  may  be,  and  often  is,  inter- 
mittent. The  crucial  test  of  the  sufficiency  of  the  kidneys  is  the  amount  of  urea 
that  they  eliminate.  Under  ordinary  circumstances  a  healthy  man  should  excrete 
in  twenty-four  hours  from  240  to  420  grains  of  urea,  a  w^oman  somewhat  less. 
No  one  can  safely  be  given  a  general  anesthetic  when  the  total  urea  falls  below 
100  grains,  and  a  total  quantity  of  200  grains  should  put  the  surgeon  on  his 
guard.  The  total  quantity  passed  in  twenty-four  hours  should  also  be 
ascertained,  the  specific  gravity  learned,  and  on  the  basis  of  this,  an  estimate 
of  the  daily  excretion  of  urea  made.  A  ready  method  of  ascertaining  the  total 
amount  of  urea  in  twenty-four  hours,  which  is  approximately  correct,  is  as 
follows :  ^Multiply  the  fluid  ounces  passed  in  twenty-four  hours  by  the  last  two 
figures  as  expressed  in  the  specific  gravity;  this  gives  the  total  amount  of 
solids  in  grains.  Divide  the  result  by  2,  and  this  will  give  the  amount  of  urea 
in  grains.  Example:  Total  quantity  50  oz.,  sp.  gr.  1018;  18  X  50  =  900  -^  2 
=  450  (B  a  r  1 1  e  y).  In  fact,  the  necessities  of  a  life  insurance  examination 
are  insignificant  as  compared  with  the  demands  of  a  properly  conducted  inquiry 
before  administering  an  anesthetic. 


EFFECTS   OF  ETHER  291 

Just  before  the  commencement  of  the  anesthetic  the  administrator  should 
examine  the  patient's  mouth  for  false  teeth  or  other  objects  which  may  become 
cli.sijlaccd  and  obstruct  respiration.  The  nose  and  throat  may  be  cleansed  with 
ad^•antago  with  a  warm  normal  salt  solution.  In  debilitated  patients  the  pre- 
liminary administration  of  an  enema  consisting  of  half  a  pint  of  saline  solution 
with  two  ounces  of  brandy  is  of  service. 

Effects  of  Ether. — These  are  usually  divided  into  four  stages. 
In  the  first  stage,  if  the  patient  experiences  suddenly  the  irritating  prop- 
erties of  the  vapor,  there  will  be  closure  of  the  glottis,  repeated  acts  of  swal- 
lowing, cough,  and  a  sense  of  suffocation.  There  are  certain  sensory  disturb- 
ances, such  as  flashes  of  light  and  exaggeration  of  sounds;  singing  in  the 
ears  and  hammering  noises  are  experienced ;  pricking  sensations  may  be  felt 
throughout  the  body.  The  pulse  is  accelerated  and  the  pupils  are  large  and 
mobile. 

Loss  of  consciousness  marks  the  commencement  of  the  second  stage.  Just 
as  this  condition  supervenes,  however,  m  some  cases,  a  period  of  excitement 
occurs,  in  which  the  patient  may  shout,  sing,  or  make  vigorous  struggling 
efforts  with  the  arms  and  legs.  When  these  are  only  slight,  they  should  not  be 
restrained.  Tonic  convulsive  movements  are  observed  in  some  cases;  in  others 
the  muscular  contractions  are  clonic.  Tremors  may  be  present  (ether  tremor). 
]\Iucus  and  saliva  are  sometimes  freely  secreted.  The  pupils  are  mobile  and 
somewhat  dilated.  The  pulse  is  full  and  bounding.  The  features  are  flushed 
and  the  conjunctivae  injected.  The  breathing  is  often  irregular  and  some- 
times restrained  or  even  suspended.  The  latter  may  be  corrected  by  per- 
mitting the  patient  to  breathe  a  little  air.  As  the  respirations  become  more 
and  more  regular  the  muscles  acting  on  the  jaw,  as  well  as  those  of  the  larynx, 
which  are  sometimes  thrown  into  a  state  of  spasm,  become  relaxed  and  slight 
stertor  is  present. 

In  the  third  stage  the  respirations  become  regular  and  stertorous,  the 
extremities  flaccid,  and  the  cornea  insensitive.  The  respiratory  efforts  are 
increased  in  frequency  and  are  forcible  and  distinctly  audible,  particularly  if 
mucus  is  present  in  the  fauces  and  larynx.  j\Iasseteric  spasm  occurs  now  and 
again,  necessitating  the  pushing  of  the  jaw  forward.  This,  with  irregularities 
in  breathing,  indicates  that  the  patient  is  passing  back  into  the  second  stage. 
The  pulse  is  slower  than  in  the  second  stage  but  is  still  more  rapid  than  normal. 
The  pupils  are  of  moderate  size  or  slightly  dilated.  Both  eyeballs  may  be 
fixed  in  the  horizontal  plane  or  both  may  slowly  move.  There  may  be  loss  of 
associated  movements,  one  eyeball  being  fixed  while  the  other  slowly  moves 
( W  a  r  n  e  r) . 

The  fourth  stage  of  etherization  is  the  stage  of  danger,  and  should  never 
be  reached.  In  it  respiratory  failure  occurs;  the  pupils  become  more  dilated; 
pallor  gives  place  to  a  dusky  hue  of  the  surface ;  the  eyelids  are  slightly  sepa- 
rated; the  pulse  becomes  less  forcible  and  sometimes  slower. 

With  the  occurrence  of  respiratory  failure  the  stertor  first  ceases  and  then 
the  breathing  efforts  become  less  and  less  forcible,  shallow,  and  slower;  in  some 
cases  the  breathing  is  jerky,  intermittent,  and  gasping. 

If  one  or  more  of  the  phenomena  above  described  occur  in  connection  with  a 
sensitive  conjunctiva,  they  are  due  to  causes  other  than  an  overdose  of  ether. 


292 


SURGICAL   ANESTHESIA 


The  invariable  rule  should  be  to  watch  the  patient  carefully,  both  during-  and 
after  the  anesthesia. 

Methods  of  Administering  Ether. — Two  systems  of  administering 
ether  are  recognized,  ^'iz.,  the  open  and  the  close.  When  the  open  system 
is  employed,  a  plentiful  supply  of  air  is  allowed  with  the  ether.  In  the  close 
system  the  suppl}'  of  air  is  restricted,  the  patient  breathing  to  and  fro  into 
a  rubber  bag  or  other  ether  device  attached  to  the  face-piece  of  the  inhaler. 

Open  System  of  Administration. — While  ether  may  be  administered 
by  means  of  an  improvised  inhaler  cone  consisting  of  a  towel  and  newspaper 
folded  together  and  fashioned  into  proper  shape,  with  a  sponge  or  bundle  of 
gauze  forced  into  the  opening  left  at  the  apex  of  the  cone,  yet  it  is  desirable  to 
furnish  as  large  an  evaporating  surface  as  possible,  and  at  the  same  time  permit 
the  free  ingress  and  egress  of  air.  This  may  be  accomplished  by  A  1 1  i  s  '  s 
inhaler  (Fig.  59).  The  apparatus  is  to  be  placed  over  the  face  and  the  patient 
told  to  breathe  deeply,  in  order  to  gain  his  confidence.  The  ether  is  then  to  be 
dropped  on  the  inhaler  in  a  steady  succession  of  drops  scattered  over  the 
margins  of  the  evaporating  surface  of  the  inhaler.     As  the  effects  of  the  anes- 


Fig.  69.  Fig.  60, 

Figs.  59  and  60. — Allis's  Ether  Inhaler. 

Showing  fenestrated  metallic  frame  with  a  muslin  roller  in  course  of  application,  and  the  inhaler  complete 

with  cover. 


thetic  become  manifest,  the  entire  area  is  moistened,  after  which  the  ether  is 
allowed  to  run  in  a  small  stream  until  the  muslin  material  of  the  inhaler  be- 
comes well  saturated,  in  which  condition  it  is  to  be  maintained  until  the  patient 
is  thoroughly  anesthetized.  This  method  of  gradually  increasing  the  strength 
of  the  ether  vapor  prevents  the  feeling  of  suffocation  commonly  experienced 
when  some  of  the  other  forms  of  inhaler  are  used,  and  permits  the  larynx  to 
become  accustomed  to  the  vapor,  whereby  the  respiratory  rhythm  is  but  little, 
if  at  all,  interfered  with. 

The  administration  should  be  rapidly  pushed  as  the  patient  becomes  semi- 
unconscious,  it  being  borne  in  mind  that  at  every  free  and  deep  inspiration 
almost  the  entire  bulk  of  ether  is  removed  from  the  inhaler.  It  is  therefore 
incumbent  on  the  administrator  to  keep  up,  without  intermission,  a  constant 
supply  of  ether  to  the  inhaler,  every  portion  of  the  evaporating  surface  being 
kept  equally  moist,  until  the  patient  is  completely  under  its  influence.     In  this 


INIETHODS  OF   ADMINISTERING   ETHER 


293 


numiier  the  minimum  amount  of  ether  is  used,  and  the  patient  anesthetized  in 
from  three  to  five  minutes.  The  stage  of  excitement  is  very  much  shortened 
anil  may  not  occur  at  all. 

The" objections  urged  against  the  open  system  by  some  surgeons  are  (1) 
tlie  larger  quantities  of  ether  needed  to  secure  and  maintain  anesthesia;  (2) 
the  difficulty  of  anesthetizing  alcoholic  subjects;  (3)  the  waste  of  ether  and  the 
presence  of  the  vapor  in  the  room;  (4)  the  more  prolonged  stage  of  excitement 
when  })resent ;  (5)  the  greater  risks  of  bronchial  and  pulmonary  affections. 

Close  System  of  Administration.— This  system  is  largely  used  abroad, 
particularlv  in  Great  Britain.  In  Clover's  inhaler  (Fig.  61)  the  face- 
piece  fits  the  face  accurately  and  the  patient  breathes  backward  and  for- 
ward into  the  attached  rubber  bag,  the  ether  being  contained  m  a 
spheric-shaped    reservoir    placed    in   the    body    of    the    instrument.     This 


Fig.  61. — Clover's  Ether  Inhaler. 


reservoir  is  surrounded  by  water  to  prevent  the  apparatus  from  becoming  too 
cold.  There  are  no  valves  and  no  provision  for  the  ingress  of  fresh  air.  The 
apparatus  is  fitted  closely  to  the  face  and  the  rubber  bag  attached  while  the 
patient  is  making  an  expiratory  movement.  This  fills  the  rubber  bag  with 
expired  air,  which  the  patient  breathes  for  half  a  minute  before  the  ether  vapor 
is  turned  on.  No  fresh  air  is  permitted  until  signs  of  cyanosis  appear,  associated 
with  stertorous  breathing,  or  there  is  impairment  of  respiration  or  circulation. 
When  it  is  necessarv  to  admit  fresh  air,  the  inhaler  is  removed  for  two  or  three 
breaths.  When  fufl  surgical  anesthesia  is  established,  the  minimum  amount  of 
ether  vapor  is  permitted  to  pass  to  the  face-piece,  and  air  is  admitted  m  suf- 
ficient quantities  to  prevent  cvanosis.  The  object  of  the  administration  is  to 
give  as  little  air  as  possible  short  of  producing  actual  cyanosis.  The  less  air 
given,  the  less  ether  will  be  required.  The  more  air  the  patient  is  permitted 
to  breathe,  the  more  ether  will  be  required  to  maintain  surgical  anesthesia. 


294 


SURGICAL   ANESTHESIA 


0  r  m  s  b  y  '  s  inhaler,  as  improved  by  H  e  ^v  i  1 1 ,  has  an  arrangement  to 
permit  the  giving  of  air  with  the  ether  vapor  in  varying  proportions;  or 
either  all  air  or  all  ether  may  be  inhaled.  The  ether  ls  poured  on  a  sponge, 
the  metal  compartments  containing  it  being  fitted  with  a  removable  water 
chamber  to  prevent  the  sponge  from  becoming  too  cold  (Fig.  62).  In  using 
Ormsby's  inhaler  the  sponge  is  first  wrung  out  of  warm  water,  the 
water  chamber  removed  and  immersed  in  hot  water  for  a  few  minutes,  and  then 
replaced.  Half  an  ounce  of  ether  is  poured  on  the  sponge,  and,  with  the  air- 
stop  open,  the  inhaler  is  gradually  brought  toward  the  patient's  face.  The 
patient  is  encouraged  to  breathe  deeply. 

Clover's  inhaler  is  undoubtedly  the  best  of  the  close  inhalers  for  inducing 
anesthesia,  while  0 r  m  s  b  y '  s  has  some  advantages  over  C 1  o  v  e  r '  s  in  maintain- 
ing the  anesthetic  effect.  The  latter,  however,  is  more  economic  in  respect  to 
ether.  The  use  of  0  r  m  s  b  y '  s  inhaler  is  attended  by  more  struggling  while  the 
patient  is  being  anesthetized,  but  is  well  adapted  for  administering  ether  after 

precedent  anesthesia  by  ni- 
trous oxid. 

The  Semi-close  System. 
— This  is  a  compromise 
between  the  open  method, 
with  its  waste  of  ether  and 
difficulty  of  anesthetizing 
alcoholic  and  vigorous  sub- 
jects, and  the  close  method, 
with  its  complicated  appa- 
ratus and  asphyxial  tenden- 
cies. The  success  of  the 
open  method  shows  that 
anesthetization  can  be  accomplished  even  with  the  constant  free  access  of  fresh 
air.  The  admission  of  sufficient  air  to  carry  the  ether  vapor,  yet  not  enough 
to  dilute  the  latter  unduly,  is  desirable.  Lrkewise,  it  is  of  advantage  both  in 
the  saving  of  ether  and  in  the  keeping  of  the  evaporating  surface  warm,  to  find 
some  means  whereby  the  full  force  of  each  expiration  is  not  exerted  to  drive  the 
expired  air,  with  a  certam  amount  of  ether  vapor,  directly  from  the  inhaler 
into  the  room.  In  accomplishing  this,  the  retention  of  the  expired  air  in 
the  inhaler  for  a  time  is  necessar\^,  but  the  evils  of  this  are  minimized  by  the 
constant  accession  of  fresh  air  which  is  mingled  with  the  previously  expired  air 
as  it  is  reinhaled. 

An  inhaler  devised  with  the  above  objects  in  view  (Fig.  63,  A)  consists  of  a 
flattened  cylinder  of  metal,  with  one  end  closed.  An  opening  on  each 
side  near  the  closed  end  serves  for  feeding  the  ether  on  the  evapoiating 
surface.  The  latter  consists  of  upholsterer's  curled  hair.  The  openings 
likewise  serve  the  purpose  of  admitting  sufficient  air  to  reinforce  the  expired 
air  to  a  sufficient  extent.  The  size  of  these  openings  may  be  regulated  as 
required.  Two  metal  gutters  are  placed  on  the  inside  of  the  inhaler  to  catch 
whatever  superfluous  ether  may  be  poured  into  the  inhaler  and  lead  it  to  a 
smaU  vent  hole  as  a  telltale  on  each  side  of  the  inhaler. 

While  using  this  inhaler  the  patient's  head  is  turned  to  one  side,  in  order  to 
permit  the  mucus  and  saliva  to  accumulate  in  the  lateral  portion  of  the  pharynx,. 


Fig.  62. — Ormsby's  Ixhaler. 
A,  Rubber  bag;    B,  sponge;    C,  adjustable  cap  for  regulat- 
ing the  admission  of  air;    D,  tube  for    conducting  air  above  the 
sponge;    E,  metal  face-piece  T\-ith  vdre  cage  for  sponge;    F,  in- 
flatable cushion  for  face-piece. 


METHOD   OF  ADMINISTERING  CHLOROFORM 


295 


and  the  iiassago  of  these  through  the  glottic  ojjening,  with  the  attendant  risks 
of  inhalation  i)neumonia,  is  thus  avoided.  The  patient  breathes  through  the 
inhaler  for  a  minute.  This  serves  to  impart  confidence  and  at  the  same  time 
warms  the  inhaler.  Ether  is  then  placed  in  small  quantities  on  the  evaporating 
surface  through  the  slot  which  is  uppermost,  the  quantity  being  gradually 
increased  as  the  second  stage  is  reached,  until  finally  a  small  stream  keeps  the 
evaporating  surface  thoroughly  charged  with  the  anesthetic  agent.  I'his  is  con- 
tinued until  the  patient  reaches  the  third  stage,  or  that  of  surgical  anesthesia. 

The  curled  hair  possesses  advantages  over  the  sponge,  cotton,  and  gauze 
materials  usually  employed,  in  that  its  meshes  do  not  become  easily  clogged 
and  hence  comjiaratively  impermeable.  It  is  likewise  easily  sterilized  by 
boiling  in  water  and  may  be  used  over  and  over  again. 

Method  of  Administering  Chloroforni. — Here  also  a  special  appara- 
tus  is   advantageous,  though  the  agent  may  be  administered  by  means  of 


Fig.  63. — Anesthetizing  Outfit. 
A,  Semiclose  ether  inhaler;    B,  dropper  bottle  for  ether;    C,  Esmarch  chloroform  mask;    D,  dropper 
bottle  for  chloroform ;   E,  screw-gag;   F,  lever-gag;  G,  tongue-forceps;  H,  needle  threaded  with  silk  suture 
for  securing  the  tongue;   I,  hypodermic  syringe  and  medicine  glass;  J,  ethyl-bromid  tube;  K,  measuring 
glass  and  hypodermic  tablets. 


a  folded  napkin  or  handkerchief.  The  mask  of  Esmarch,  consisting  of  a 
wire  frame,  shaped  to  fit  the  face,  covered  with  a  merino  material,  is  the  best 
devised  (Fig.  63,  C).  A  modification  of  this  by  S  c  h  i  m  m  e  1  b  u  s  c  h  permits 
the  ready  change  of  the  woven  material  used  as  an  evaporating  surface  and 
also  presents  the  advantage  of  being  capable  of  being  folded.  As  in  ether,  the 
administration  of  chloroform  should  be  begun  by  placing  the  mask  over  the 
face  and  bidding  the  patient  breathe  deeply  a  few  times.  Then  only  a  drop  or 
two  should  be  placed  on  the  apparatus  by  means  of  the  dropper  bottle  (Fig.  63, 
D),  the  stopcock  of  which  should  be  graduated  so  as  to  permit  slow  dropping 
only.  Each  part  of  the  mask  should  receive  a  drop  of  the  chloroform  in  turn, 
the  anesthetizer  thus  keeping  up  a  constant  supply.  Chloroform  should 
always  be  kept  in  a  well-stoppered  dark  bottle,  in  order  to  exclude  the  white 
rays  of  light,  under  the  influence  of  which  it  is  decomposed  into  hydrochloric 
acid,  chlorin,  free  formic  acid,  etc. 


296 


SURGICAL   ANESTHESIA 


The  position  of  the  patient  should  always  be  the  recumbent  one  in  chloro- 
form narcosis,  with  the  head  lowered;  it  is  even  recommended  that  the  body 
should  be  placed  at  an  angle  of  45  degrees,  the  head  depending. 

The  preliminary  hypodermic  injection  of  morphin  (Nussbaum)  is 
recommended,  in  order  to  lessen  the  amount  of  chloroform  or  ether  required. 
As  a  stimulant  to  the  respiratory  centers  atropin  is  also  recommended  to  be 
given  hypodermically.  The  preliminary  hypodermic  injection  of  spartein  and 
morphin  as  a  cardiac  tonic  is  recommended  (Langlois;  Maurange). 
The  anesthetizer  should  not  permit  his  attention  to  be  diverted  while  carefully 
watching  the  patient's  condition.  He  should  constantly  keep  his  finger  on  the 
temporal  or  facial  artery,  carefully  watch  the  patient's  breathing  and  the 
corneal  and  pupillary  reflexes,  as  well  as  the  color  of  the  skin. 

Special  Dangers  from  Ether  Narcosis. — The  dangers  from  ether  inhal- 
ation are  mainly  those  arising  from  asphyxia,  and  not,  as  a  rule,  from  heart 
failure,  though  the  latter  may  occur.  For  this  reason,  though  the  heart  is 
not  to  be  neglected,  the  greatest  watchfulness  is  to  be  kept  over  the  respira- 
tions.    Usually  there  is  some  warning  of  danger  during  ether  narcosis,  symp- 


FiG.  64. — Junker's  Inhaler  Arranged  for  Administering  Chloroform  through  the  Nose. 
A  safety-pin  is  passed  across  the  nasal  tube  to  prevent  the  latter  from  slipping  too  far  in. 


toms  of  asphyxia  coming  on  gradually.  The  first  appearance  of  these  should  be 
met  promptly  by  withdrawing  the  ether,  and  permitting  the  patient  to  breathe 
air  for  a  while  until  the  cyanosis  ceases.  The  operator  may  note  the  dark  color 
of  the  blood  in  the  operation  wound  and  notify  the  anesthetizer  of  the  fact. 
In  case  of  weak  or  failing  respirations,  artificial  respiration  should  be  resorted 
to  (Sylvester's,  see  page  300).  In  case  of  coincident  cardiac  failure  the 
method  of  stimulating  the  heart  recommended  in  Chloroform  Narcosis  should 
be  resorted  to  (see  page  298). 

The  After=effects  of  Ether. — The  most  common  immediate  after- 
effects of  ether  are  nausea,  retching,  and  vomiting.  These  are  far  less 
likely  to  occur  if  the  patient's  stomach  is  entirely  empty  at  the  time  of  the 
administration.  This,  together  with  the  use  of  the  purest  ether,  reduces  these 
symptoms  to  a  minimum.  Sometimes  the  nausea  and  vomiting  come  on  just 
as  the  patient  is  recovering  consciousness.  More  commonly,  however,  they 
take  place  while  he  is  unconscious.  These  symptoms  are  rarely  the  cause  of 
anxiety  to  the  surgeon. 

Bronchitis,  pulmonary  edema,  and  pnevunonia  occasionally  occur  after 
etherization  (see  page  285).     When  they  take  place,  it  is  not  always  clear  that 


THE  EFFECTS  OF  CHLOROFORM  297 

the  other  is  to  be  held  res))()nsil)le.  Then*  occurrence  is  to  be  provided  against, 
however,  by  a  proper  examination  of  the  chest  organs,  and  by  a  postjionement 
of  the  operation,  whenever  possible,  in  those  suffering  from  bronchial  catarrh 
or  other  abnormal  conditions  of  the  respiratory  organs.  Other  precautionary 
measures  are  (1)  keeping  the  patient's  head  turned  well  to  one  side  during  the 
administration  in  order  to  avoid  inhalation  of  mucus  and  saliva;  (2)  avoiding 
all  unnecessary  exposure  to  wet  coverings,  drafts,  etc.,  while  the  patient  is  on 
the  operating  table  and  after  he  has  been  removed  to  his  room. 

Ether  has  been  accused  of  causing  albuminuria,  nephritis,  and  uremia. 
It  is  now  believed  that  these  conditions  rarely  occur  except  in  cases  in  which  they 
have  been  present  beforehand.  Mental  disturbances,  choreiform  move- 
ments, hemiplegia  from  cerebral  hemorrhage,  and  jaundice  are  likewise  to 
be  mentioned  as  rare  sequences  of  the  use  of  ether. 

The  Effects  of  Chloroform. — The  phenomena  of  chloroform  anesthesia 
are  very  similar  to  those  of  ether.  During  the  first  stage,  however,  the 
sense  of  suffocation,  swallowing,  coughing,  and  holding  the  breath  are,  as  a 
rule,  absent.  This  is  owing  to  the  fact  that  the  vapor  of  chloroform  is  more 
pleasant  to  inhale  than  that  of  ether. 

During  the  second  stage  mental  excitement  and  struggling  are  somewhat 
less  common  than  when  ether  is  administered,  particularly  where  the  open 
method  of  administering  the  latter  is  employed  by  those  unaccustomed  to  its 
use.  In  muscular  and  alcoholic  male  subjects,  as  well  as  in  hysteric  and  excit- 
able women,  there  is  more  or  less  rigidity,  with  attempts  to  rise  to  the 
sitting  position,  incoherent  gesticulations,  etc.  Tonic  spasm  and  irregular 
breathing  may  occur  in  some  subjects  in  this  stage;  these  pass  away,  however, 
and  the  advent  of  regular  respirations,  with  slight  snoring,  marks  the  third 
stage  of  anesthesia. 

In  the  commencement  of  the  second  stage  the  pulse  is  accelerated,  but  as 
the  third  stage  is  approached  it  becomes  normal.  The  pupils  are,  as  a  rule, 
mobile  and  more  or  less  dilated,  and  react  sluggishly,  if  at  all,  to  light.  As  the 
anesthesia  deepens  they  tend  to  become  smaller  and  more  fixed. 

The  Third  Stage.— As  in  the  case  of  ether,  the  third  stage  of  the  effects  of 
chloroform  marks  the  presence  of  surgical  anesthesia.  The  respirations,  how- 
ever, are  more  quiet,  though  in  plethoric,  flabby,  and  obese  subjects  there  may 
be  more  or  less  stertor,  and  some  rigidity  of  the  jaw  muscles.  Except  in  this 
class  of  cases  it  is  not  necessary,  as  a  rule,  to  keep  the  jaw  pushed  forward  m 
order  to  maintain  free  respiration.  Indeed,  at  times  the  breathing  may  be 
so  quiet  under  chloroform  as  to  awaken  anxiety. 

The  circulation  is  more  sluggish  under  chloroform  than  under  ether.     In 
the  third  stage  the  pulse  may  become  even  slower  than  the  normal.     In  some 
"  cases  in  which  it  was  comparatively  feeble  in  the  first  and  second  stages  it  is 
found  to  grow  stronger  in  the  third  stage. 

The  behavior  of  the  eve  reflexes  is  almost  identical  with  that  under  ether 
anesthesia.  The  pupil  i^  moderately  contracted  and  averages  somewhat 
smaller  than  in  etherization.  The  pupil  is  an  important  guide  in  the  admmis- 
tration.  When  it  is  verv  small,  the  patient  is  not  well  under  the  chloroform, 
and  when  it  is  somewhat  dilated  either  the  anesthesia  is  dangerously  deep,  or 
the  dilatation  is  of  reflex  origin  and  is  associated  with  a  light  anesthesia.     The 


298  SURGICAL    ANESTHESIA 

lid  reflex  is  abolished  and  continues  so  as  long  as  the  patient  remains  in  the 
third  stage. 

The  muscular  system  is  completely  relaxed  under  full  cliloroform  an- 
esthesia. The  color  of  the  face  is  at  first  heightened;  afterward  there  is  a 
tendency  for  it  to  become  paler  than  the  normal,  particularly  when  the  patient 
is  coming  out  from  the  anesthetic  and  when  vomiting  is  about  to  occur.  The 
temperature  is  always  reduced. 

Special  Dangers  from  Chloroform  Narcosis. — The  majority  of 
fatalities  in  chloroform  narcosis  occur  early  in  the  administration,  i.  e.,  in  the 
second  stage  and  at  the  commencement  of  the  third,  and  in  muscular  and 
alcoholic  subjects,  as  well  as  in  hysteric  and  excitable  patients. 

Evidence  of  great  mental  excitement,  when  present,  indicates  caution  in 
the  administration.  This,  together  with  irregular  and  shallow  breathing,  is 
to  be  met  by  a  plentiful  dilution  of  the  chloroform  vapor  with  air.  Prolonged 
tonic  spasm  is  a  particularly  dangerous  feature.  The  general  contraction  of  all 
the  muscles  of  the  body  forces  the  venous  blood  to  the  right  heart,  from  which 
it  is  prevented  from  escaping  by  the  embarrassment  of  the  pulmonary  circula- 
tion incident  to  the  want  of  fresh  air.  The  right  heart,  being  incapable  of 
emptying  itself,  is  unable  to  contract  and  becomes  distended;  unless  the  con- 
ditions are  quickly  relieved  the  patient  dies  from  acute  cardiac  dilatation. 
The  administration  must  be  suspended  and  the  patient  made  to  breathe  by 
forcible  and  intermittent  pressure  on  the  base  of  the  thorax,  or,  if  necessary,  by 
artificial  respiration.  Aid  in  "breaking"  the  spasm  of  the  respiratory  muscles 
is  sometimes  afforded  by  forcibly  dilating  the  sphincter  ani. 

Clonic  movements  affecting  the  arms,  whereby  the  latter  are  jerked  more 
or  less  rhythmically  toward  the  median  line  of  the  body,  are  due  to  spasm  of 
the  pectoral  muscles.  These  should  be  regarded  as  strongly  indicating  the 
necessity  for  air  (Hewitt). 

Cardiac  failure  may  result  from  an  overdose  of  chloroform,  or  it  may  occur 
quite  independently  of  this,  as  shown  by  the  fact  that  sudden  syncope 
arises,  in  some  instances,  at  the  commencement  of  the  inhalation,  due  in  a 
measure  to  excessive  fright  and  apprehension.  Such  sudden  deaths  oc- 
curring at  the  commencement  of  the  operation  were  not  unknown  prior  to  the 
introduction  of  anesthetics.  The  freedom  of  ether,  as  well  as  of  nitrous 
oxid  narcosis  from  these  fatalities  is  due  to  the  fact  that  ether  stimulates 
the  heart  and  thus  counteracts  the  depressing  effects  of  the  mental  emo- 
tion, and  nitrous  oxid  serves  to  overcome  fear  by  quickly  abolishing  con- 
sciousness. 

Fatal  syncbpe  may  arise  in  connection  with  vomiting,  or  efforts  at  vomit- 
ing, due  to  faulty  or  too  sparing  administration.  The  presence  of  undigested 
food  is  specially  liable  to  lead  to  this  complication. 

Asphyxia!  complications  leading  to  acute  cardiac  dilatation  have  been 
already  alluded  to  {vide  supra).  Many  of  the  cases  of  death  under  chloroform 
attributed  to  pure  cardiac  failure  are  probably  due  to  a  feeble,  fatty,  or  dilated 
heart,  the  action  of  which  is  still  further  hampered  by  minor  degrees  of  respira- 
tory embarrassment . 

Treatment  of  Dangerous  Chloroform  Narcosis. — The  supervention 
of  dangerous  symptoms  in  chloroform  narcosis  must  be  met  by  withdrawing 
the  anesthetic,  lowering  the  head,  elevating  the  lower  extremities,  drawing 


TREATMENT  OF  DANGEROUS  CHLOROFORM  NARCOSIS 


299 


the  tongue  forward,  and   making  artificial  respiration.     The  Sylvester 
method  is  the  preferable  one.     The  dashing  of    hot   and  cold  water    alter- 
natel}'  on  the  chest  and  abdomen  is  recommended  by  some,  but  is  of  doubtful 
utility.     The  same  may  be  said  of  hypodermic  injections  of  the  various  drugs 
recommended.     These  cannot  be  absorbed  while  the  circulation  is  enfeebled, 
and  there  is  danger  that  their  repeated  administration  may  lead  to  the  absorp- 
tion of  an  overdose  when  the  heart's  action  is  restored  by  other  measures. 
This  should  be  borne  in  mind  when  such  powerful  alkaloids  as  strychnin, 
cocain,    digitalin,    and   atropin   are   used.     The   following   points   should   be 
considered  when  these  drugs  are  employed  in  dangerous  chloroform  narcosis : 
(1)  Strychnin  is  a  most  powerful  stimulant  to  both  the  heart  and  the  respiratory 
centers.     To  be  efficient  it  must  be 
given  in  large  doses  in  watery  solu- 
tion, from  4o    to   yV   of   ^   g^^^^ 
being  required  in  the  case  of   an 
adult.     Its   effect  on  the  respira- 
tion is  first  observed ;    that  on  the 
heart  occurs  more  gradually.     (2) 
Cocain  is  a  stimulant  to  the  res- 
piration and  may  be  given  advan- 
tageously    in     combination     with 
strychnin.     These   alkaloids   given 
conjointly  exercise  a  more  power- 
ful   influence    than    either    given 
separately    (Wood).     From   half 
a  grain  to  a  grain  may  be  admin- 
istered in  an  emergency.    (3)  Digi- 
talis is  indicated  preliminarily  for 
those  with  a  weak  heart,  and    it 
may  also  be  given  in  cardiac  failure 
under  the  anesthetic.     (4)  Atropin 
is  a  useful  stimulant   to   the  res- 
pirations alone.     Its  use  is  more 
frequently  indicated  in  ether  than 
in  chloroform  narcosis 
to  -,-L,  of  a  2-rain  is  the  dose.     These 


From  J-g- 
Y^  of  a  grain  is  the  dose, 
drugs   may  be    given   hypodermi 


Fig.  65. 


-Sylvester's  Method  of  Artificial  Res- 
piration (Expiration). 


cally,  though  their  effect  will  not 

be  apparent  unless  the  circulation 

is  reestablished.     For  this  reason  their  administration  should  not  be  repeated 

frequently  nor  at  too  short  intervals,  lest  the  patient  be  overwhelmed  by  the 

final  absorption  of  an  accumulated  dose. 

While  these  drugs  are  being  prepared  and  administered,  a  heated  compress 
or  a  hot-water  bag  should  be  placed  over  the  pericardial  region.  At  the  same 
time  the  diaphragm  may  be  stimulated  to  contraction  through  the  phrenic 
nerve  by  placing  one  pole  of  a  faradic  battery  in  the  epigastric  region  and  the 
other  at  the  outer  border  of  the  sternomastoid  muscle  at  its  lowermost  por- 
tion. This  should  not  take  the  place  of  the  work  of  making  artificial  respira- 
tion nor  be  permitted  to  interfere  with  it. 


300 


SURGICAL    ANESTHESIA 


Artificial  Respiration. — This  is  employed  more  frequently  for  the  re- 
storation of  patients  suffering  from  dangerous  surgical  narcosis  than  in  any 
other  connection.  It  should  be  commenced  as  soon  as  respiration  actualh^ 
ceases,  as  shown  by  the  absence  of  all  thoracic  and  abdominal  movements,  the 
absence  of  evidences  of  air  passing  from  the  mouth  or  nose,  and  the  signs  of 
deepening  cyanosis. 

Sylvester's  Method. — The  head  and  neck  should  be  fully  extended,  the 
former  hanging  over  the  end  of  the  table;  the  tongue  is  well  drawn  forward  to 
prevent  possible  obstruction  to  the  entrance  of  air.  The  arms  are  grasped  at 
the  elbows  and  pressed  firmly  for  about  two  seconds  against  the  sides  of  the 
chest  (Fig.  65).     If  this  does  not  cause  an  expiration,  the  pressure  should  be 

made  below  the  costal  margins 
in  the  direction  of  the  dia- 
phragm. The  arms  are  now 
brought  upward  to  each  side  of 
the  head,  inspiration  being  ef- 
fected by  thus  increasing  the 
capacity  of  the  chest  through  the 
action  of  the  pectoral  muscles  on 
the  upper  ribs  (Fig.  66).  These 
movements  are  kept  up  at  the 
rate  of  about  fifteen  times  a  min- 
ute. With  the  occurrence  of 
spontaneous  efforts  at  breathing, 
care  must  be  taken  to  supplement 
rather  than  substitute  the  normal 
respiration.  The  artificial  move- 
ments are  occasionally  suspended 
in  order  to  judge  of  the  efficiency 
of  the  normal  efforts. 

Laborde's  method  of  rhyth- 
mic traction  of  the  tongue  is 
sometimes  successful  in  restoring 
the  respiratory  reflex.  The  tongue 
is  grasped  by  forceps  and  alter- 
nate traction  and  relaxation  made 
about  twenty  times  a  minute. 
This  is  kept  up  for  at  least  half 
an  hour,  unless  respiration  is  es- 
tablished in  the  meanwhile.  This  method  may  be  employed  alone  or  in 
conjunction  with  other  methods. 

Intralaryngeal  insufflation  consists  in  forcing  air  from  a  bellows  into  the 
lungs  through  an  intubation  attachment  (F  e  1 1  -  0  '  D  w^  y  e  r  method). 
Provision  is  made  for  the  escape  of  the  expired  air  through  a  branch  tube. 
A  modification  of  this  apparatus  consists  of  the  substitution  of  a  graduated 
pump  for  the  bellows,  and  the  addition  of  a  mercurial  manometer  and  auto- 
matic cut-off  for  preventing  the  backward  leakage  of  air.  This  improved 
apparatus  is  also  arranged  for  administering  oxygen  or  an  anesthetic  while 
artificial  resj^iration  is  being  carried  on  (]\I  a  t  a  s). 


Fig.  66. 


-Sylvester's  Method  of  Artificial  Res- 
piration (Inspiration). 


PRIMARY   anesthesia;  I'liECEDENT    ANESTHESIA 


301 


Primary  Anesthesia.— It  has  been  suggested  that  advantage  may  be 
taken  of  a  period  of  rather  complete  anesthesia  which  is  said  to  intervene 
between  the  connnencement  of  the  a(hriinistration  and  the  occurrence  of  the 
stage  of  excitement.  The  patient  is  requested  to  hold  up  his  arm  and  main- 
tain it  in  that  position  as  long  as  he  possibly  can.  When  it  is  no  longer  vol- 
untarily held,  a  very  short  operation,  such  as  an  incision  for  an  abscess  lasting 
for  not  more  than  ten  seconds,  may  be  performed.  It  is  not  always  possible 
positively  to  identify  this  stage,  if,  indeed, it  is  of  constant  occurrence.  On  the 
other  hand,  some  surgeons  assert  that  there  are  certain  dangers,  particularly 
those  resulting  from  sudden  shock,  which  arise  from  the  attempt  to  proceed 
with  an  operation  of  any  kind  before  the  patient  is  fully  anesthetized.  Many 
European  surgeons,  however,  prefer  to  operate  as  soon  as  the  stage  of  ex- 
citement is  over  and  l^efore  complete  relaxation  is  established. 

Precedent  Anesthesia.— The  use  of  anesthetic  agents  which  produce  rapid 
yet  transient  anesthesia  has  been  advocated  for  the  purpose  of  abolishing  the 
stage  of  excitement  incident 
to  the  employment  of  ether, 
as  well  as  of  lessening  the 
length  of  time  occupied  in 
producing  anesthesia,  and 
hence  the  amount  of  ether 
used.  The  agent  of  this 
class  in  most  common  use  is 
nitrous  oxid,  or  laughing 
gas.  Chlorid  of  ethyl  and 
bromid  of  ethyl  have  also 
been  employed.  Nitrous 
oxid  possesses  the  advan- 
tage of  not  inducing  a  stage 
of  excitement ;  the  agent  it- 
self is  practically  without 
taste  or  smell  and  is  abso- 
lutely nonirritating  to  the 
respiratory  tract;    hence  its 

administration  excites  no  resistance  on  the  part  of  the  patient.  The  necessary 
apparatus,  however,  is  somewhat  bulky  and  complicated.  Nevertheless,  there 
can  be  no  question  that  in  experienced  hands  the  use  of  nitrous  oxid  precedent 
to  ether  has  great  advantages,  in  selected  cases,  over  the  employment  of  ether 
in  the  usual  manner. 

Chlorid  of  ethyl  (T  u  1 1 1  e)  and  bromid  of  ethyl  (Fowler)  are  equally 
efficient,  and  less  expensive  as  to  the  cost  of  both  the  agent  and  the  necessary 
apparatus.  The  absence  of  excitement  cannot  always  be  assured,  and  the  odor, 
particularly  in  the  case  of  bromid  of  ethyl,  induces  repugnance,  and  hence,  in 
some  instances,  resistance  to  its  use.  In  order  to  obtain  the  best  results  from 
chlorid  of  ethyl  it  is  necessary  to  use  a  special  inhaler,  the  agent  being  sprayed 
on  the  inhaler  until  the  effect  is  obtained.  In  the  case  of  bromid  of  ethyl  the 
amount  necessary  to  induce  anesthesia,  from  three  to  four  drams  for  an 
adult,  is  placed  on  a  closed  ether  inhaler,  and,  all  air  being  excluded,  the  pa- 
tient inhales  this  for  about  one  minute,  or  until  the  pupils  are  widely  dilated  or 


Fig. 


67. — Ware's  Apparatus  for  the  Opex  Admixistratio.v 
OF  Ethyl  Chlorid. 

1,  Funnel-shaped  rubber  face-piece;  2,  tube  over  the  end 
of  which  two  layers  of  gauze  are  stretched;  .3,  neck  of  the  face- 
piece  into  which  the  end  of  the  tube  with  its  gauze  covering 
is  forced. 


302 


SURGICAL   ANESTHESIA 


the  usual  signs  of  surgical  anesthesia  are  present.     Sulfuric  ether  is  then  sub- 
stituted for  the  bromicl  of  ethyl. 

Anesthesia  by  Means  of  Nitrous  Oxid. — This  agent  is  largely  employed 
by  dentists  in  tooth  extraction.  Its  use  is  usually  restricted  to  opera- 
tions of  short  duration,  though  it  has  been  employed  in  operations  of  an 
hour  or  more  in  length.  It  requires  special  skill  in  its  administration  and  a 
special  and  somewhat  complicated  apparatus  as  well.  For  painful  redressings, 
when  the  patient  dreads  them,  and  when  ether  or  chloroform  cannot  be 
repeatedly  used  for  passing  urethral  sounds,  etc.,  it  has  been  employed  with 
advantage.     It  enters  the  blood  bv  diffusion  throu2:h  the  thin  walls  of  the 


Fig.  68. — Ethyl  Chlorid  Tube. 


alveoli  of  the  lungs.  While  its  anesthetic  properties  are  manifesting  themselves, 
the  patient's  respirations  become  labored  and  stertorous  and  finally  very  shal- 
low. A  cyanotic  hue  spreads  over  the  surface,  and  it  is  not  until  this  occurs 
that  complete  anesthesia  is  established.  The  latter  lasts  but  a  moment  or  two 
after  the  agent  is  withdrawn,  which  must  be  done  before  respiration  ceases 
altogether,  else  the  danger-line  is  reached. 

Paul  Bert  (1875),  by  mixing  together  80  volumes  of  nitrous  oxid  and 
20  of  oxygen,  succeeded  in  obtaining  an  anesthetic  agent  the  great  advantage  of 
which  consists  in  the  fact  that  all  the  reflexes  necessary  to  life  are  present,  while 
complete  anesthesia  is  established,  the  normal  condition  returning  as  soon  as 

the  inhalation  is  suspended. 
The  general  introduction  of 
this  mixture  is  very  much 
embarrassed  by  the  compli- 
cated and  cumbersome  ap- 
paratus necessary  for  its  use. 
Ethyl  Chlorid  as  a 
General  Anesthetic. — The 
employment  of  this  agent 
for  the  purpose  of  general 
anesthesia  is  indicated  in 
minor  operations  of  short 
duration.  It  may  be  administered  with  the  patient  either  in  the  horizontal 
or  in  the  sitting  position.  It  is  said  that,  with  the  exception  of  nitrous 
oxid,  it  is  the  least  dangerous  of  general  anesthetics,  and  that  neither  cardiac, 
respiratory  or  renal  affections,  nor  pregnancy  contraindicates  its  use.  It  may 
be  administered  to  old  and  young  alike.  It  is  pleasant  in  its  effects  and 
rapid  in  its  action. 

Anesthesia  is  preceded  by  an  analgesic  stage,  lasting  for  a  fraction  of  a 
minute;  this  is  followed  by  tonic  contractures,  increased  frec{uency  of  the 
respirations,  and  moderate  dilatation  of  the  pupils.  Short  operations  may  be 
performed  in  this  stage.     The  third  stage,  or  that  of  profound  anesthesia,  is 


Fig.  69. — Daniels's  Modification  of  the  Clover  Ether  In- 
haler, FOR  Ethyl  Chlorid  Administration. 


DISTURBANCES    OF   THE    NORMAL    COURSE    OF    ANESTHESIA  303 

reached  in  from  a  quarter  of  a  minute  to  a  minute  later,  according  to  the  age 
of  the  patient  and  the  method  employed.  In  full  anesthesia  the  muscles  are 
relaxed;  the  respirations  are  deep  and  regular,  with  snoring  in  some  cases; 
the  conjunctival  reflex  is  abolished  and  the  pupils  somewhat  dilated.  From  1 
to  5  c.c.  of  ethyl  chlorid  are  necessary  to  produce  the  third  stage;  1  c.c.  given 
about  every  minute  thereafter  suffices  to  maintain  the  anesthetic  effect. 

Either  the  close  or  the  open  method  may  be  employed,  preferably  the 
latter  by  those  not  accustomed  to  its  use.  W  are's  apj^aratus  is  the 
simplest  (Fig.  67)  for  open  administration;  the  ethyl  chlorid  is  sprayed  on  the 
gauze  from  the  ethjd  chlorid  tube  (Fig.  68)  as  reciuired.  For  the  close 
method  Daniels's  modification  of  the  Clover  portable  ether  inhaler  is 
useful  (Fig.  69).  The  ethyl  chlorid  is  placed  in  the  graduated  glass  ^•ial,  and 
the  latter  connected  with  the  tube  and  stopcock  of  the  nitrous  oxid  attach- 
ment of  the  apparatus  by  means  of  a  piece  of  red  rubber  tubing.  The  flow  of 
ethyl  chlorid  is  regulated  by  the  stopcock. 

Only  a  pure  article  should  be  employed.  The  preparation  known  as 
"kelene,"  the  ethyl  chlorid  of  B  e  n  g  u  e  ,  or  that  of  H  e  n  n  i  n  g  ,  of  Ber- 
lin, may  be  used. 

Disturbances  of  the  Normal  Course  of  Anesthesia.— The  distur- 
bances of  the  normal  course  of  anesthesia  may  be  divided  into  those  which 
occur  during  the  period  of  excitement  and  those  wliich  occur  during  the  period 
of  relaxation.  Among  those  which  occur  in  the  first  period  are  to  be  noted 
uncontrollable  and  violent  struggling  and  vomiting. 

Violent  struggling  is  attended  by  some  dangers,  particularly  in  cases 
where  chloroform  is  employed  and  in  alcoholics.  In  this  class  of  patients  there 
is  sometimes  alarming  cyanosis,  demanding  immediate  withdrawal  of  the 
anesthetic.  The  suggestion  to  administer  to  alcoholics  hypodermically  a  full 
dose  of  morpliin  fifteen  or  twenty  minutes  beforehand  is  a  valuable  one.  It 
renders  the  patient  much  more  amenable  to  the  anesthetic  agent. 

Nausea  and  vomiting  also  occur  before  the  patient  is  fully  under  the  in- 
fluence of  the  anesthetic,  particularly  if  he  has  partaken  of  food  or  drink  during 
the  preceding  few^  hours.  This  vomiting  may  become  a  source  of  grave  danger 
on  account  of  the  passage  of  the  vomited  matter  into  the  air-passages,  produc- 
ing suffocation.  On  the  occurrence  of  this  complication  the  patient's  head 
should  be  turned  to  the  side  so  as  to  facilitate  the  expulsion  of  food  from  the 
fauces  and  mouth.  If  this  does  not  suffice,  the  index-finger  is  to  be  forced 
over  the  back  of  the  tongue,  bent  like  a  hook,  and  used  to  withdraw  any  mass 
of  food  lying  in  the  fauces.  The  stomach  being  once  emptied,  the  anesthetic 
may  be  proceeded  with.  The  occurrence  of  deep  anesthesia  will  serve  to  assist 
the  retching  which  sometimes  follows  the  emptying  of  the  stomach. 

In  case  suffocation  threatens  during  vomiting,  tracheotomy  should  be  at 
once  resorted  to.  The  inspired  portions  of  food  will  usually  be  coughed  out 
of  the  tracheal  wound. 

A  condition  of  asphyxia  is  sometimes  observed  to  come  on  without  any 
preliminary  vomiting.  It  is  noticed  that  the  patient  makes  vigorous  efforts 
at  breathing  but  no  air  enters  the  glottic  opening.  The  patient's  face  be- 
comes bluish-red  and  finally  deep  purple  or  dark  blue.  As  anesthesia  ad- 
vances, the  muscles  of  the  tongue  become  paralyzed,  and  this  organ  sinks, 
from  its  own  weight,  so  as  to  occlude  the   chink  of  the  glottis.     Under  these 


304  SURGICAL   ANESTHESIA 

circumstances  the  fingers  of  the  anesthetizer,  placed  behind  the  angles  of  the 
jaw  on  each  side,  flex  the  head  sharply  backward  and  at  the  same  time  force 
the  lower  jaw  anteriorly,  so  as  to  cause  its  lower  incisors  to  project  as  far  as 
possible  beyond  the  incisors  of  the  upper  jaw.  The  anterior  insertion  of  the 
geniohyoglossus  is  thus  forced  forward  and  the  tongue  must  necessarily  follow. 
K  a  p  p  e  1  er  seizes  the  body  of  the  hyoid  bone  and  drags  it  anteriorly,  to- 
gether with  the  base  of  the  tongue.  If  this  maneuver  fails  to  lift  the  tongue 
away  from  the  glottis,  this  may  be  effected  by  grasping  it  with  the  tongue 
forceps  (Fig.  63,  G),  or  an  ordinary  pair  of  dressing  or  hemostatic  forceps. 
If  it  is  necessary  to  continue  the  lifting  of  the  tongue,  less  injur}-  will  be  in- 
flicted if  a  thread  is  passed  through  the  organ,  made  into  a  loop  and  held  by 
the  anesthetizer.  The  thread  should  be  passed  crosswise  to  the  tongue  near 
its  dorsal  surface,  at  a  point  behind  the  attachment  of  the  frenum,  in  order 
to  prevent  dragging  on  the  latter.  Sometimes,  even  in  spite  of  this,  it  will  be 
necessarj^  to  press  the  tongue  downward  and  forT\-ard,  by  the  aid  of  the  finger 
placed  in  the  mouth. 

When  masseteric  spasm  is  present,  the  jaws  should  be  forced  apart  by  a 
screw-gag  (Fig.  63,  E),  and  a  lever  mouth-gag  (Fig.  63,  F)  introduced  to  hold 
the  lower  jaw  do-um.  The  arrested  ingress  of  air  and  ether  vapor  incident  to  the 
blocking  of  the  upper  air-passages  by  the  base  of  the  tongue  is  frequently  due 
to  the  combined  effects  of  masseteric  spasm  and  involuntary  efforts  at  swallow- 
ing. Forcing  open  the  mouth  by  a  gag,  so  as  to  put  the  muscles  freely  on  the 
stretch,  relieves  the  spasm,  interrupts  the  swallowing  act,  and  gives  access  to 
the  cavity  of  the  mouth  for  the  purpose  of  either  depressing  or  drawing  forward 
the  tongue  and  clearing  the  fauces  of  mucus  or  saliva. 

Anesthesia  in  Face  Operations. — Full  surgical  anesthesia  is  first  estab- 
lished, after  which  the  pharynx  is  cocainized.  Two  full  sized  drainage-tubes 
are  passed  through  the  nares  to  the  level  of  the  epiglottis  and  allowed  to 
project  beyond  the  nose  a  sufficient  distance  to  permit  the  administration  of 
the  anesthetic  away  from  the  field  of  operation.  The  mouth  is  then  widely 
opened,  the  tongue  drawn  out,  and  the  pharynx  packed  with  large  pieces  of 
gauze.  If  the  base  of  the  tongue  is  carried  well  forward  an  air  chamber  is 
formed,  with  which  the  rubber  tubes  and  the  larynx  communicate.  A  Junker 
inhaler  (Fig.  69),  or  other  apparatus  for  vaporizing  the  anesthetic  agent,  may 
be  connected  with  one  of  the  tubes. 

^yhen  this  method  is  employed,  the  patient  may  be  placed  in  the  position 
best  suited  to  the  operative  technic,  regardless  of  the  flow  of  blood.  The  flow 
of  mucus  usuafly  incident  to  operations  within  the  cavity  of  the  mouth  is 
absorbed  by  the  gauze  (C  r  i  1  e). 


LOCAL  ANESTHESIA 

This  is  best  effected  by  the  use  of  cocain  hydrochlorate.  LocaUy  applied 
this  drug  produces  anesthesia,  and,  in  addition,  a  condition  of  anemia  due  to 
contraction  of  the  arterioles.  The  mucous  membranes  are  promptly  rendered 
anesthetic;  the  intact  skin,  however,  is  not  affected  by  the  drug.  Personal 
idiosyncrasy  is  an  important  factor  in  its  use.  In  those  specially  susceptible 
to  its  effects  a  few  drops  of  a  4  or  6  per  cent  solution  in  the  eye  or  nasal 
passages,  or  ^  of  a  grain  administered  hypodermicaUy,  may  produce  alarm- 


LOCAL    ANESTHESIA  305 

ing  depression.  Experiments  on  animals  show  lliat  the  fall  of  blood-pres- 
sure following  such  nianii)ulations  as  ordinarily  produce  shock,  abdominal 
section  and  manipulation  of  the  intestines,  manipulation  of  the  larynx,  stimu- 
latiim  of  the  vagi,  etc..  is  inhibited  by  the  effects  of  cocain  (C  r  i  1  e). 

In  the  surgery  of  the  immediately  accessible  mucous  membranes,  e.  g.,  the 
nasoi)har\-nx,  larynx,  urethra,  bladder,  etc.,  solutions  of  from  4  to  6  per  cent  are 
necessary. 

In  order  to  secure  the  anesthetic  effects  of  cocain  in  tissues  other  than 
mucous  membranes  it  is  necessary  to  luring  the  drug  in  contact  with  these 
either  through  the  use  of  hypodermic  injection  or  by  prolonged  contact  through 
wounds  or  incisions. 

The  Sterilization  of  Cocain  Solutions.— This  is  best  accomplished 
by  repeatedly  heating  the  solutions  to  a  point  just  below  the  boiling-point 
(fractional  sterilization) .     Boiling  injures  the  anesthetic  qualities  of  the  cocain. 

The  Local  Infiltration  Method  (H  a  1  s  t  e  d  ,  S  c  h  1  e  i  c  h).— This 
consists  in  mjecting  a  0.1  per  cent  solution  into  the  substance  of  the  skin. 
The  resulting  elevation  of  the  epidermis  is  called  a  wheal.  The  first  wheal  is 
made  by  introducmg  the  needle  in  a  slightly  ol^hque  du-ection  for  a  short  dis- 
tance only.  The  needle  is  then  advanced  and  a  small  quantity  again  injected. 
Successive  wheals  are  thus  formed  in  the  area  to  he  incised.  In  operations 
involving  deeper  parts  these  must  be  cocainized  in  the  same  manner.  In 
larger  areas,  in  order  to  avoid  the  toxic  effects  of  the  drug,  edema  of  the  parts 
obtained  by  the  injection  of  normal  salt  solution  will  produce  anesthesia  in 

these. 

Perineural  Infiltration.— This  consists  in  infiltration  of  the  tissues 
about  the  nerves  supplving  the  parts  to  be  operated  on,  proximal  to  the  point 
of  intended  operation  '(Halsted,  Oberst).  A  constrictmg  bandage  is 
placed  about  the  parts  a  short  distance  above  the  seat  of  operation  (Corning). 
The  anesthetic  effects  are  enhanced  and  the  toxic  effects  lessened  by  the 
retention  of  the  solution  in  the  tissues  for  from  half  an  hour  to  an  hour.^  The 
constriction  should  be  just  sufficient  to  arrest  the  volume  flow  of  blood  in  the 
vessels.  The  tissues  about  each  nerve  supplying  the  parts  are  infiltrated. 
The  mjected  solution  should  be  retained  for  at  least  half  an  hour,  by  keeping 
the  bandage  on  for  that  length  of  time. 

Intraneural  Infiltration.— The  nerve-trunk  is  first  exposed  by  the 
ordinary  infiltration  method,  and  then  injected  with  from  0.25  to  0.5  per  cent 
cocain  solution.  The  first  injection  is  made  beneath  the  sheath  of  the  nerve; 
the  substance  of  the  nerve  is  then  injected  (C  r  i  1  e  .  31  a  t  a  s).  _  Not  only  does 
the  injected  cocain  render  the  operation  painless,  but  the  physiologic  ''block" 
produced  arrests  all  afferent  unpulses  and  thus  prevents  shock. 

The  preliminarv'  injection  of  a  dose  of  morphin  (i  to  i  of  a  grain)  is  recom- 
mended in  all  cases  of  cocain  anesthesia. 

Eucain  /?,  the  hydroclilorid  of  benzoyl,  is  sometmies  used  as  a  sub- 
stitute for  cocam.  on  account  of  its  much  less  pronounced  toxic  properties 
when  large  quantities  are  to  be  employed.  It  can  be  sterilized  by  boUmg 
and  its  solution  will  remam  unchanged.  For  the  bladder  or  urethra  4  per 
cent  solutions  are  emploved.  Solutions  of  from  1  to  2  per  cent  are  employed 
for  perineural  and  intraneural  injections.  The  resulting  anesthesia  is  more 
rapidly  produced  but  is  less  lasting  than  cocain  anesthesia. 
21 


306  SURGICAL    ANESTHESIA 

Tropacocain  Hydrochloric!. — This  is  derived  from  a  special  variety 
of  coca  plant  found  in  Java.  It  is  said  to  be  less  toxic  than  cocain  and  to  pro- 
duce a  more  rapid  and  trustworthy  anesthesia. 

Nirvanin. — This  is  a  synthetic  product.  It  is  freely  soluble  in  water. 
When  used  on  sensitive  mucous  membranes,  such,  for  instance,  as  the  conjunc- 
tiva, a  temporary  irritation  precedes  the  anesthetic  effect.  The  anesthetic 
effect  is  in  proportion  to  the  sensitiveness  of  the  surface  to  this  precedent  irri- 
tation. It  is  specially  adapted  for  subcutaneous  use,  the  resulting  anesthesia 
being  complete  and  prolonged.  It  is  used  in  from  2  to  5  per  cent  solutions. 
The  solution  may  be  boiled  without  injury  to  the  drug.  Its  toxic  ciualities  are 
said  to  be  less  than  those  of  cocain  and  eucain.  Antiseptic  properties  also  are 
claimed  for  it. 

Orthoform. — This  synthetic  compound  occurs  as  a  white  and  very 
light  powder.  Its  slight  solubility  in  water  renders  it  useless  for  subcutaneous 
administration.  Its  employment  is  limited  to  applications  to  painful  lesions 
of  the  skin  and  mucous  membranes.  It  is  used  as  a  dusting-powder  or  in  a 
10  or  20  per  cent  ointment.  It  may  be  given  internally  in  doses  of  from  74^  to 
15  grains  for  the  relief  of  gastralgia.  Loss  of  sensation  occurs  in  from  three  to 
five  minutes  following  its  application  to  an  ulcerated  surface  or  an  open 
wound,  and  lasts,  according  to  C  h  e  a  t  h  a  m  ,  for  from  thirty  hours  to  three 
or  four  days  (P  a  1 1  o  n).  Its  value  as  a  dusting-powder  is  enhanced  by  its 
drying  action.  Finally,  it  may  be  applied  freely  and  for  protracted  periods 
without  fear  of  toxic  effects. 

Aneson. — A  watery  solution  of  acetone  chloroform  is  known  by  this  name. 
Its  anesthetic  effect  is  more  Ciuickly  produced  than  that  following  cocain,  but 
is  less  pronounced.  It  is  used  in  1  or  2  per  cent  solution  for  application  to  the 
conjunctiva  and  the  nasal,  pharyngeal,  and  laryngeal  mucous  membranes. 
The  solutions  are  said  to  be  antiseptic  and  hence  sterile.  It  may  also  be  used 
subcutaneously.     It  is  said  to  be  both  nontoxic  and  nonirritant. 

Ethyl  Chlorid  (Kelene). — The  local  anesthetic  effects  of  ethyl  chlorid 
are  due  to  the  intense  cold  produced.  It  is  furnished  in  hermetically  sealed 
tubes  (Fig.  68)  with  a  screw  cap  covering  a  fine  point.  The  liquid  is  expeUed 
from  the  latter  by  the  warmth  of  the  hand,  in  a  fine  stream,  which  is  directed  on 
the  surface  to  be  anesthetized.  Temporary  congelation  occurs,  as  evinced  by 
the  white  solid  appearance  of  the  anesthetized  spot.  The  anesthetic  effect 
ceases  in  a  few  minutes.  Its  inflammability  necessitates  caution  in  its  use  near 
an  open  flame. 

Liquid  Air. — This  has  been  used  as  a  local  anesthetic  in  the  shape  of  a 
spray.  As  in  ethyl  chlorid  anesthetization,  the  anesthetic  effect  depends  on 
congelation.  A  slight  tingling  accompanies  the  process.  In  order  to  obtain 
the  best  results  the  parts  should  be  frozen  solid.  The  freezing  effect  produced 
lasts  for  about  twenty  minutes  and  is  succeeded  by  hyperemia.  It  is  some- 
times used  to  alleviate  neuralgic  pains.  It  has  also  been  employed  to  abort 
furuncles,  buboes,  etc.,  and  has  been  applied  at  intervals  of  three  or  four  days 
as  a  stimulant  to  chancres,  chancroids,  and  indolent  ulcers. 

SPINAL  ANESTHESIA 

This  is  more  properly  termed  "spinal  analgesia,"  since  only  the  sensation  of 
pain  is  abolished  by  its  use.     The  effect  is  obtained  by  the  injection  of  cocain 


SIMXAL    ANESTHESIA  307 

into  the  siibchiral  space  in  the  lower  dorsal  and  upper  lumbar  regions  of  the  cord 
and  Cauda  equina  (Corning).  Pure  crystallized  h}'drochlorate  of  cocain  is 
sterilized  by  exposure  for  fifteen  minutes  to  a  dry  temperature  of  300°  F.  and 
kept  in  sterile  tubes  until  needed.  The  dose  varies  from  -}  to  H-  grains  accord- 
ing to  the  effect  desired.  Complete  analgesia  of  the  entire  bod}',  except  the 
head,  may  be  obtained  by  this  method.  In  exceptional  cases  the  scalp  to  the 
vertex  also  becomes  analgesic.  A  glass  hypodermic  syringe  with  asbestos 
piston  is  easily  sterilized  by  boiling  and  is  the  best  instrument  to  employ.  The 
edges  of  the  beveled  point  of  the  needle  should  be  ground  off  to  prevent 
punching  out  a  portion  of  the  skin.  The  injection  may  be  made  with 
the  patient  sitting,  or,  better  still,  lying  on  the  side  with  the  back  curved. 
The  needle  is  introduced  between  the  third  and  the  fourth  lumbar  ver- 
tebra. Its  entrance  into  the  subdural  space  is  announced  by  the  escape  of 
a  few  drops  of  cerebrospinal  fluid.  The  cocain  is  dissolved  in  30  minims  of 
sterile  water,  the  syringe  attached  to  the  needle,  and  the  solution  slowly  in- 
jected. The  needle  puncture  is  sealed  with  a  drop  of  collodion.  Or  the 
cocain  may  be  placed  dry  in  the  syringe  barrel,  the  latter  screwed  in  place, 
and  sufficient  cerebrospinal  fluid  withdrawn  to  effect  the  solution  of  the  cocain, 
which  is  then  injected. 

The  analgesic  effect  is  obtained  in  from  five  to  ten  minutes.  Exceptionall}^ 
a  longer  time  is  required.  The  abolition  of  sensation  usually  commences  in 
the  feet  and  gradually  extends  upward.  The  average  height  reached  is  the  level 
of  the  umbilicus.  "With  larger  quantities  of  the  solution  greater  diffusion  is 
obtained,  but  the  use  of  larger  doses  of  the  drug  is  followed  by  alarming  symp- 
toms of  faintness,  nausea  and  vomiting,  and  signs  of  collapse.  On  the  other 
hand,  larger  dilutions  of  a  safe  dose  may  lead  to  faihu-e.  The  effect  lasts  from 
forty-fiA'e  minutes  to  three  hours. 

All  operations  on  the  lower  extremities,  genitals,  anal  region,  bladder,  and 
groins  (hernia,  etc.)  may  be  performed  under  spinal  analgesia.  Ovariotomy, 
hysterectomy,  appendectomy,  gallbladder  operations,  and  even  operations  on 
the  thorax  have  been  performed  by  this  method.  The  last-named  operations, 
however,  are  not  advisable,  for  the  reasons  above  given. 

The  method  should  not  be  used  as  a  routine  procedure  and  can  never  replace 
ether  and  cliloroform.  The  toxic  effects  of  cocain  (great  depression,  profuse 
sweating,  etc.),  as  well  as  the  symptoms  due  to  increased  tension  (intense  head- 
ache), are  common.  Besides  these,  the  nausea  and  vomiting  are  frequently 
persistent,  together  with  relaxation  of  the  sphincters  and  cramps  in  the  limbs. 
Overaction  of  the  heart  and  precordial  distress  are  not  uncommon.  Old  and 
somewhat  feeble  patients,  in  my  experience,  suffer  less  from  these  s}'mptoms 
than  the  young  and  vigorous. 

Spinal  cocainization  should  be  reserved  for  those  individuals  in  whose  cases, 
on  account  of  the  presence  of  either  heart  disease,  pulmonary  disease,  or  renal 
disease,  a  general  anesthetic  is  contraindicated. 


SECTION  X 


THE  GENERAL  PRINCIPLES  OF  OPERATIVE 

TECHNIC 

THE  SEPARATION  OF  TISSUES 
Tissues  are  separated  or  divided  for  either  diagnostic  or  therapeutic  pur- 
poses.    Exploratory  incisions  are  employed  for  reaching  deeply  placed  dis- 
eased foci  for  purposes  of  inspection  and  palpation. 

Indications.— d  J  The  separation  of  the  destroyed  tissues  from  the  intact 

tissues  in  recent  injuries;  (2)  the  fash- 
ioning of  irregular  wound  surfaces  for 
coaptation;  (.3)  aid  in  the  search  for 
foreign  bodies;  (4)  the  exposures  of 
bleeding  vessels  for  purposes  of  ligation; 
(o)  the  introduction  of  drainage-tubes; 
(Q)  the  evacuation  of  the  products  of 
inflammation  (pus  and  other  debris); 
(7)  access  to  inflamed  structures  for 
the  removal  of  infected  tissues,  blood- 
clot,  etc.,  and  the  appUcation  of  anti- 
-eptic  remedies;  (8)  the  extirpation  or 
destruction  of  tumors;  (9)  the  removal 
of  parts  hopelessly  infected  or  diseased; 
nOj  plastic  procedures  and  the  correc- 
tion of  deformities;  (11)  hgation  of 
blood-vessels  in  continuity;  (12)  trans- 
fusion; (13)  the  expsoure  of  underlying 
uarts  to  be  operated  on,  as  in  trephin- 
ing; (14)  abdominal  section  or  celiot- 
omy; (1.5)  herniotomy. 

Means  Employed. — The  following 

are   the  pjrincipal  means  employed  for 

-eparation  of  the  tissues:    (1)  cutting 

instruments;     (2)    blunt    instruments, 

including  the  elastic  and  wire  ligature; 

(3)    cauterization;     (4)  puncture;   (5) 

the  sharp  spoon  or  curet. 

Cutting   Instruments. — lliese  include  the  scalpel  and  its  modifications, 

the  scissors,  for  separation  of  the  soft  parts,  and  the  saw,  the  chisel,   the 

cutting  forceps,  and  the  drill,  for  the  osseous  and  cartilaginous  .structures. 

The  scalpel  (Fig.  70)  is  employed  for  free-hand  incisions  and  dissections 
of  the  soft  parts.  The  blade  should  be  solidly  attached  to  the  handle,  as  in 
the  case  of  those  with  hard-rubber  handles  in  which  the  handle  is  vulcanized 

308 


70. — Scalpels. 


TIIK    SEPARATION    OF    TISSUES 


309 


on  the  stem  of  tho  ])la(lo  (Tiemann);  citlior  this,  or  the  entire  instrument 
should  be  forged  in  one  piece.  The  blade  may  be  narrow  and  pointed  for 
puncturing  and  short  incisions,  and  broad  and  convex,  or  "bellied"  on 
its  cutting-edge,  for  long  incisions  and  extensive  dissections.  Scalpels 
with  slightly  concave  blades  (hollow  ground)  are  preferable.  The  handle 
should  afford  a  firm  and  easy  grasp  for  the  thumb  and  fingers  and  the  extrem- 
ity of  this  part  of  the  instrument  should  have  a  "fish  tail"  shape  for  blunt 
dissection.  A  double-edged  scalpel  is  useful  in  certain  plastic  operations. 
Knives  with  stout  handles  which  may  l)e  grasped  with  the  entire  hand  are  pro- 
vided with  short  heavy  blades  for  operations  on  bones  and  joints  and  with  long 
blades  for  amputations.  The  bistoury  (Fig. 
71)  is  another  modification  of  the  scaljjel.  It 
may  be  straight  or  curved  and  pointed  or 
blunt. 

In  the  separation  of  tissues  from  without 
inward,  it  is  necessary  in  some  localities,  on 
account  of  the  loose  connections  of  the  skin 
to  the  underlying  structures,  to  make  tension 
on  the  tissues  in  order  to  facilitate  incision. 
The  skin  may  be  put  on  the  stretch  (1)  by  the 
thumb  and  finger-tips  of  the  surgeon's  left 
hand;  (2)  by  the  hands  of  the  surgeon 
and  his  assistant;  (3)  by  the  flexion  or 
extension  of  joints,  and  rotation  and  ex- 
tension of  the  head  in  operations  about  the 
neck.  After  the  skin  has  been  incised,  the 
underlying  structures  are  steadied  by  anat- 
omic or  thumb  forceps  (Fig.  72),  held  by 
the  surgeon  himself,  by  his  assistant,  or,  bet- 
ter still,  when  the  latter  is  well  trained,  by 
both.  Different  forms  of  fixation  forceps 
have  been  devised  for  special  operations, 
such  as  the  double  tenaculum  forceps  (Fig. 
73)  for  grasping  tumors  and  steadying  the 
same  during  enucleation,  and  the  ring-bladed 
or  fenestrated  clamp  (Fig.  74),  for  grasping 
soft  parts  which  would  otherwise  tear  if 
grasped  by  tenacula,  such  as  hemorrhoids 
during  extirpation. 

The  different  methods  of  holding  the  scalpel  are  shown  in  Figs.  75,  76,  and 
77.  The  surgeon's  own  tact  and  ingenuity  will  suggest  to  him  the  conditions  to 
which  these  positions  are  best  adapted. 

Incisions  from  Within  Outward. — These  are  made  either  with  a 
probe-pointed  or  a  sharp  bistoury ;  when  emplo^^ed  to  enlarge  or  to  expose  the 
extent  of  a  fistulous  tract,  a  curved  blade  answers  best.  When  a  pointed 
bistoury  is  used  for  this  purpose,  it  is  prevented  from  penetrating  beyond 
the  fistula  or  sinus  by  the  preliminary  introduction  of  a  grooved  director  as 
a  guide  (Figs.  79  and  80).  Except  under  these  circumstances  and  in  special 
cases,  such   as   external   urethrotomy   and   perineal   lithotomy,  the  surgeon 


Fig.  71. — Bistouries. 


310  THE    GENERAL   PRINCIPLES   OF   OPERATIVE   TECHNIC 

should  depend  on  his  knowledge  of  anatomy  and  execute  incisions  in  a  free- 
hand manner. 

Separation   of  the   Tissues  by  Means  of   Scissors.— The   blades  of 
the  scissors  should  be   properly  fitted  and  well  sharpened,    in   order  that 


Fig.  72. — Anatomic  or  Thumb  Forceps. 


the  incision  should  be  as  clean  as  possible;  at  the  best  the  tissues  are  more 
or  less  pinched  and  contused  by  the  opposing  blades.  The  steadiness  with 
which  the  parts  are  held  by  the  scissors  as  they  are  incised  constitutes  an 
advantage  in  the  use  of  this  instrument.     They  should  not  be  employed  where 


Fig.  73. — Double  Tenaculum  Forceps. 


the  vitality  of  the  structures  is  already  impaired  and  gangrene  or  sloughing  is  to 
be  feared.  The  hand,  in  grasping  the  scissors,  covers  more  or  less  the  field  of 
operation  and  obstructs  the  view.  This  is  obviated  somewhat  by  scissors 
curved  on  the  flat  (Fig.  81,  A).  In  prolonged  operations,  as,  for  instance,  in 
removing  multiple  lymphomas  from  the  cervical  region,  the  alternate  use  of  the 


Fig.  74. — Ring-shaped  Pile  Forceps. 


knife  and  scissors  lessens  the  fatigue  incident  to  the  continuous  use  of  one 
instrument,  inasmuch  as  different  sets  of  muscles  are  employed  for  each. 

Besides  straight  scissors  and  those  curved  on  the  flat,  there  are  other  shapes 
which  may  be  advantageously  employed,  e.  g.,  angular  or  those  curved  on  the 
side  (Fig.  81,  C). 


TTTE    SEPARATION    OF    TISSUES  311 

The  Separation  of  Bone.— This  is  accomplished  l\v  means  of  the  saw 
and  its  modilications,  chisels,  cutting  forceps,  and  drills.  Saws  are  made  with 
solid  broad  blades  for  sawing  squarely  across  the  bone  (Fig.  82).     A  narrow 


Fig.  75. — Method    of   Holding   the   Scalpel   for   a  Long  Sweeping  Incision. 


Fig.  76. — Method   of  Holding  the  Scalpel  for  Dissecting. 


Fig.  77. — Scalpel  Held  Like  a  Violin-bow. 


blade  fixed  in  a  frame  is  useful  in  making  irregularly  shaped  cuts  (Fig.  83). 
The  chain  saw  and  the  wire  saw  are  used  in  separating  bone  from  within  out- 
ward (see  page  312). 


312 


THE  GENERAL    PRINCIPLES    OF   OPERATIVE    TECHNIC 


Fig.  78. — Method  of  Holdixg  Bistouhy. 
Cutting  upward  as  in  opening  an  abscess. 


In  commencing  the  section  the  saw  should  be  drawn  at  first  across  the  bone 
from  the  heel  to  the  point  of  the  instrument  in  the  direction  toward  the  operator, 
in  order  to  secure  a  groove  for  the  subsecjuent  strokes  of  the  instrument.     This 

preliminary  backward  stroke  can 
be  made  more  steadily  than  a  for- 
ward stroke  over  the  smooth  bony 
surface,  so  that  the  operator  is 
thus  enabled  to  place  the  groove 
at  the  proper  point,  the  saw  sub- 
sequently following  the  groove  in 
completing  the  section. 

The  chain  saw  (Fig.  145)  is 

made  of  a  numl^er  of  links  con- 

^^^^Vji    ^^Bi^ltT  nected  together  like  the  links  of 

^^BFJ^mwf^  mH^^^  ^     ^  chain,  the  teeth  being  set  upon 

"^^^  ^Ji^l^^\mmlt% fmmm     the  links.     A  handle  is  attached 

to  each  end,  the  saw  being  moved 
by  pulling  on  one  or  the  other 
handle. 

The  wire  saw  of  G  i  g  1  i  (Fig. 
147)  has  largely  taken  the  place  of  the  chain  saw.     It  is  made  of  piano  wire  with 
roughened  surfaces.     It  is  more  easily  introduced  and  occupies  less  room 
when    in    position    than 
the  chain  saw.     It  is  com- 
paratively inexpensive 
and  is  much  more  readily 
cleaned      and     rendered 
aseptic  than  the  latter  in- 
strument. 

The  trephine  (Fig. 
84)  is  a  tubular  shaped 
instrument  with  saw 
teeth,  designed  for  re- 
moving button  -  shaped 
sections  of  bone.  It  is 
almost  exclusively  used 
for  the  vault  of  the  skull. 

A  pin  is  projected  beyond    the    instrument  for    the   purpose    of    steadying 
the  latter  until   a   groove   is  formed  by   a   series   of   rotating   movements. 


Fig.  79. — Cuttixg  Upward  on  a  Grooved  Director. 


Fig.  so. — Grooved  Director. 


Care  should  be  taken  that  the  point  of  the  pin  does  not  project  far  enough 
to  perforate   the  bone  before   the    groove    which   is   to   serve  for  the  sub- 


THE    SEPARATION    OF    THE    TISSUES 


313 


sequent    guidance    of    the    instrument  is  sufficiently    deep  for  the   purpose. 
Though  the  conical  and  grooved  sides  of  the  trephine  of  Gait  (Fig.  85)  are 
designed  to  prevent  a  too  sudden  com])l('ti()n  of  the  section  and  consecjuent 
injury  of  the  dura,  in  the  case  of 
the    skull    this      should     not    be 
trusted  too  implicitly.     The   in- 
strument  should   be  occasionally 
removed  and  the  debris  cleaned 
away  for  purposes  of  examination. 
The  sound  obtained  by  tapping  on 
the  button  of    l^one    at   different 
points  with  the  handle  of  the  in- 
strument   will    reveal    any    part 
which  may  have  been  cut  through 
in  advance  of  the  rest,  in  which     Fig.  81. 
case  the  trephine  should  be  tilted 
away  from  that  point. 

Drills  are  used  for  perforating  bone  for  suturing  and  for  exploratory  pur- 
poses (Figs.  86  and  87).  In  applying  the  drill  the  handle  of  the  instrument 
is  grasped  in  the  palm  of  the  hand,  the  index-finger  passing  alongside  the 


-A,    Scissors    curved   on   the  flat; 
scissors;  C,  angular  scissora. 


B,   .straight 


Fig.  82. — Broad  Saw. 


instrument  and  steadying  the  latter  until  its  point  is  engaged.  A  crochet 
needle  will  be  found  useful  in  passing  the  suture.  F  1  u  h  r  e  r  has  com- 
bined a  drill  and  crochet  needle  in  the  same  instrument  (Fig.  87). 


Fig.  83. — Frame  Saw. 


In  recent  years  the  surgical  engine,  modeled  on  the  lines  of  the  dental  engine, 
has  been  employed  for  gaining  access  to  the  cavity  of  the  skull  and  for  sawing 


314 


THE    GENERAL   PRINCIPLES    OF    OPERATIVE   TECHNIC 


and  perforating  bones  in  other  situations.  The  electric  surgical  engine  consists 
essentially  of  an  electric  motor,  a  flexible  cable  for  transmitting  the  power,  and 
various  circular  saws,   burrs,  and  drills,  together  with  proper  chucks,   and 


Fig.  84. — Roberts's  Aseptic  Trephixe. 
1,  Removable  block  and  center-pin;   2,  trephine  complete. 

clutches  for  securing  these  to  the  cable,  and  handles  for  guiding  the  application 
of  these  to  the  work  in  hand.     The  best  of  these  is  that  devised  by  D  o  y  e  n  , 

and  made  by  C  o  1 1  i  n  ,  of  Paris    (Fig. 
88). 

Chisels  are  used  for  cutting  away 
portions  of  bone  where  the  saw  cannot 
be  applied.  They  are  made  indifferent 
shapes  and  sizes,  according  to  the  var- 
ious rec{uirements  (Fig.  89).  They 
are  used  in  connection  with  the  mallet. 
The  wooden  mallet  of  the  cabinet- 
maker is  the  best  for  the  purpose. 
A  little  practice  will  enable  the  oper- 
ator to  fix  his  attention  on  the  prog- 
ress made  by  the  edge  of  the  instrument, 
rather  than  on  the  head  of  the  latter 
where  blows  of  the  mallet  are  to  fall. 

Rongeur  forceps  are  used  for  round- 
ing off  or  smoothing  rough  surfaces  of 
bone  left  after  sawing  (Fig.  90,  A). 

Cutting  forceps    (Liston's,  Fig? 

90,  B)  for    severing    small    bones    are 

used  where  the  latter  are  inaccessible  to  the  saw.     Those  supplied  with  hollow 

blades  are  used  as  a  punch  in  removing  bone  (Fig.  91).     When  the  cutting 

forceps  are  used  for  the  division  of  bones  like  the  metacarpal,  a  preliminary 


Fig.  85. — Galt's  Trephine. 


THE    SEPAKATION    OF   THE    TISSUES 


315 


groove  made  with  the  points  of  the  forceps  on  one  or  more  sides  of  the  bone  will 
prevent  extensive  splintering. 

The  sharp  spoon  or  curet  (Fig.  92)  is  used  for  removing  diseased  tissues 
from  surfaces  by  scraping  movements.  It  is  used  for  clearing  away  the  infected 
walls  of  abscess  cavities  and  sinuses,  and  the  soft  and  broken-down  parts  of 
diseased  foci  in  bone  and  other  structures  where  a  formal  dissection  is  im- 
practicable or  where  the  conditions  are  such  as  to  render  unnecessarv  the 
removal  of  the  entire  part  involved.     These  curets  are  made  in  different  sizes; 


Fig.  86. — Bone  Drill,  with  Hollow  Handle  to  Contain-  Different  Sizes  of  Drills. 

some  models  have  an  u'rigating  attachment  to  facilitate  washing  away  the 
debris  that  results  from  the  scraping. 

Separation  of  Tissues  by  Means  of  the  Ligature  and  by  Heat. — 

The  simplest  method  of  dividmg  tissues  b}'  these  means  consists  in  applying  a 
ligature  to  the  pedicle  of  a  soft  tumor,  the  latter  becoming  necrotic  and  falling 
off.  The  application  of  the  ecraseur  is  another  example  of  the  principle  of  this 
method.  The  instrument  may  be  armed  with  a  chain  or  firm  steel  wire  (Fig. 
95) ;  the  latter  is  preferred  in  removing  nasal  and  aural  polypi.  The  ligature  is 
sometimes  employed  when  no  pedicle  exists,  e.  g.,  in  angioma  of  the  skin,  by 
transfixing  the  margins  of  the  base  with  two  or  more  needles  carrying  a  thread 
in  such  a  manner  as  to  form  a  series  of  loops  beneath  the  skin  surrounding  the 


Fig.  S7. — Fluhrer's  Crochet  Drill. 


base.  By  tightening  the  loops  of  thread,  the  base  is  constricted,  a  subcu- 
taneous pedicle  formed,  and  the  ch'culation  in  the  growth  cut  off.  Elastic 
threads  may  also  be  employed  for  this  purpose. 

The  use  of  the  elastic  ligature  has  its  more  frequent  apphcation  in  the 
cure  of  fistula  in  ano.  It  has  likewise  been  used  in  effecting  lateral  anastomosis 
of  contiguous  bowel  loops  (M  c  G  r  a  w). 

The  galvanocautery  loop  is  useful  in  a  certain  class  of  cases.  The  ap- 
paratus consists  of  a  loop-carrier,  somewhat  like  an  ecraseur,  wliich  is  armed 
with  a  loop  of  platinum  wire.  The  latter  is  heated  by  a  current  of  electricity 
supplied  by  the  street  current  or  a  suitable  battery.  A  galvanocautery  knife 
ma}'  also  be  used,  as  weU  as  a  dome-shaped  instrument  for  cauterizing  flat 
surfaces.  In  addition  to  the  hemostatic  properties  of  the  galvanocautery.  an 
aseptic  effect  is  obtained  by  its  use.  Recurring  or  secondary  hemorrhage  in 
tissues  previously  acted  on  by  the  cautery  is  troublesome  to  deal  with  on 


316 


THE    GENERAL    PRINCIPLES   OF   OPERATIVE   TECHNIC 


account  of  the  difficulty  of  grasping  and  securing  the  vessels.     Wounds  made 
by  cauterization  do  not  admit  of  primary  union. 

The  thermocautery  of  Paquelin  (Fig.  96)  is  more  restricted  in  its  application 
than  the  galvanocautery ;  for  instance,  it  cannot  be  employed  as  a  hot  ecraseur. 


Fig.  88. — Doyen's  Surgical  Engine. 
1,  Electric  motor;  2,  cable  for  transmitting  the  power  together  with  handle  and  chuck  for  securing 
the  instruments;  3,  larger  saws;  4,  small  saw  secured  to  chuck  with  guard  ring  in  position;  5,  burrs; 
6,  mortise  burrs;  7,  drill;  8,  chuck  shown  separately;  9,  handle  with  guard  to  prevent  injury  of  the 
dura  and  saw  arranged  for  section  of  the  bones  of  the  skull;  10,  guard  rings  for  the  smaller  saw;  11, 
instrument  for  measuring  the  thickness  of  the   cranial  bones   after   a  small  opening  has  been  made. 


It  has,  however,  the  advantage  of  being  simpler  and  less  expensive, 
shaped  pointed  or  flattened  dome  instrument  may  be  used  at  will. 


A  knife- 


THE    SKPARATIOX    OF    THE    TISSUES 


317 


Cauterization  by  Means  of  Chemic  Substances.— These  are  divided 
into  alkaline  and  acid  substances,  and  the  salts  of  various  metals.  The 
substances  belonging  to  the  former  group  that  are  in  most  common  use  are 


Fig.  S9.— a,    Maeewen's   tapering   chisel;     B,    Macewen's   beveled  chisel;   C,    hght    tapering  chisel ;   D, 

hollow  chisel  or  gouge. 

caustic  potash  and  Vienna  paste  (potassa  cum  calce,  U.  S.  P.).  It  consists 
of  equal  parts  of  potassa  and  lime.  These  unite  with  the  water  of  the  tissues 
and  chssolve  the  albuminous  bodies.     Consequently  their  action  is  rather  widely 


Fig.   90. — A,  Rongeur  forceps;  B,  Liston's  bone-cutting  forceps. 


diffused.  Alkaline  caustics  produce  a  moist  eschar  which  favors  the  develop- 
ment of  bacteria  and  consequent  septic  processes.  Then  use.  therefore,  is 
greatly  limited. 


318 


THE    GENERAL   PRINCIPLES  OF  OPERATIVE    TECHNIC 


The  acid  caustics  include  nitric  acid,  hydrochloric  acid,  and  chromic  acid. 
These  form,  with  the  coagulated  albumin  of  the  tissues,  dry  eschars.  The 
germicidal  effects  of  the  acids  and  the  fact  that  the  action  of  these  does 


Fig.  91. — Keen's  Gouge  Forceps. 


not  extend  deeply  into  the  tissues,  constitute  very  decided  advantages  over 
the  alkaline  caustics. 

The  salts  of  certain  metals  are  also  employed.     Nitrate  of  silver,  sulfate 
of  copper,  chlorid  of  zinc,  and  compounds  of  arsenic  are  useful.     These  act  bv 


Fig.  92. — Volkmann's  Bone  Curet. 


precipitating  albuminous  substances.  Nitrate  of  silver  combined  with  chlorid 
of  silver  to  modify  its  action  has  but  a  superficial  effect;  its  use  is  restricted 
to  the  destruction  of  too  rapidly  proliferating  granulations.     Chlorid  of  zinc 


Fig.  93. — Brtjns's  Bone  Curet. 


produces  a  much  more  intense  effect,  and  the  resulting  albuminous  coagulation 
is  aseptic  to  a  high  degree.  It  may  be  applied  in  the  shape  of  a  paste  (equal 
parts  of  chlorid  of  zinc  and  flour  with  sufficient  water  to  make  a  paste),  when 


Fig.  94. — Irrigating  Curet. 


it  is  desired  to  produce  a  deeply  destructive  effect.     It  has  comparatively  slight 
effect  on  the  unbroken  skin. 

Caustic  arrows  are  designed  to  produce  separation  of  parts  by  their  eschar- 


THIO    SEPAllATION    OF    TIIIO    'I'IS.SUKS 


319 


olic  (effect.  'I'liov  contsist  of  ,stri})s  of  heavy  linen  dipjjed  in  a  strong  solution  of 
chloiiil  of  zinc.  'The  blade  of  a  scalpel  is  passed  flatwise  through  the  base  of  the 
tumor  to  be  removed,  in  a  ratUating  manner,  and  the  arrows  are  j^laced  in  the 
incisions.  The  part  becomes  necrotic  and  falls  off.  'J"he 
process  of  separation  is  an  exceedingly  painful  one. 

Puncturing  and  Aspiration. — These  methods  are 
employed  for  the  purpose  of  removing  fluids  from  a  dis- 
eased part.  The  puncture  made  under  these  circumstances 
is  only  of  a  temporary  character.  A  narrow-bladed  scalpel 
may  be  employed  for  the  purpose,  but  a  trocar  and  can- 
nula are  preferable  (Fig.  97);  or  the  latter,  when  pointed, 
may  be  employed  alone.  The  puncture  made,  the  trocar  is 
withdrawn  and  the  fluid  allowed  to  flow  through  the  can- 
nula. In  performing  the  puncture  the  index-finger  is  held 
as  a  guard  at  the  proper  point  to  prevent  the  trocar  from 
penetrating  too  deeply.  A  straight  trocar  and  cannula 
( l*'ig.  97,  A)  are  usually  employed,  but  it  may  be  an  advan- 
tage to  use  a  curved  instrument  (Fig.  97,  B) ,  as,  for  instance, 
in  puncturing  the  bladder  above  the  pubic  symphysis. 
The  pointed  cannula  or  hollow  needle  is  sometimes  used, 
but  it  has  the  disadvantage  of  placing  an  unguarded  point  in 
the  cavity  to  be  emptied.  To  obviate  this,  the  dome  trocar 
and  cannula  of  Fitch  is  used  (Fig.  98).  The  diameter 
of  the  cannula  will  vary  with  the  requirements  of  the  case.  For  fluids  of  a  thin 
character  a  small  instrument  will  suffice,  but  those  that  are  thick  and  viscid 
or  that  contain  flakes   of  lymph  will  require  a  cannula  with  large  caliber. 


Fig. 


95. — Piano-wire 
ecraseur. 


Fig.  96. — Thermocautery. 
A,  Hollow  handle  containing  absorbent  cotton — saturated  with  benzene;  B,  removable  cap;    C,  con- 
necting tubing;    D,  rubber  bulb;    E.  secondary  bulb  guarded  by  netting;    F    alcohol  lamp   and  cap;    G, 
knife-shaped  cautery  jjoint;    H,  pointed  cautery  point;    I,  dome-shaped   cautery  point;    J,  extension  at- 
tachment to  be  used  with  the  shorter  cautery  points. 


In  case  the  instrument  becomes  obstructed,  a  proper  sized  wire  is  passed 
through  it  while  in  situ  to  clear  it. 

Aspiration  is  accomplished  by  attaching  a  suction  apparatus  to  the  cannula. 


320  THE    GENERAL  PRINCIPLES    OF    OPERATIVE    TECHNIC 

The  aspirated  fluid  may  go  directly  into  the  barrel  of  the  syringe,  as  in 
Dieiilafoy's  apparatus;  or  by  exhausting  a  bottle  attached  to  the 
cannula,  the  fluid  may  be  draAATi  into  the  bottle  instead  of  into  the  barrel  of 


Fig.  97. — A,  Straight  trocar  and  cannula;  B,  curved  trocar  and  cannula. 

the  syringe  (P  o  t  a  i  n).     Puncture  for  diagnostic  purposes  is  best  performed 
by  an  ordinary  hypodermic  syringe  (Fig.  99). 


Fig.  98. — Fitch's  Dome  Trocar  and  Caxxula. 
A,  The  point  exposed  for  introduction;   B,  the  blunt  cannula  or  dome  protruded  to  guard  the  point  after 

introduction. 


The  operation  of  puncturing  should  be  performed  with  all  aseptic  precau- 
tions.    In  withdrawing    the    cannula  the   vacuum  in  the   syringe  or  bottle 


Fig.  99. — Collin's  Gl.^ss  Syrixge  with  Solid  Metal  Piston. 

should  be  preserved  in  order  to  prevent  the  entrance  of  air,  as  well  as  to  guard 
against  contact  of  the  overlying  structures  with  infectious  material  from  the 
diseased  part  which  otherwise  would  remain  in  the  point  of  the  instrument. 


INDICATIONS    FOR    UNITING    THE   TISSUES 


321 


INDICATIONS 


FOR    UNITING  THE  TISSUES; 
UNITING  THE  TISSUES 


MECHANISM   OF 


To  secure  union  of  divided  structures  is  the  first  aim  in  this  connection. 
'rh(^  ]ireHininarv  conditions  necessary  for  this  are  (1)  prevention  of  high 
grades  of  inflammation;  (2)  effective  and  permanent  coaptation  of  the 
wound  edges.  The  first  condition  is  fulfilled  partly  by  careful  aseptic  treat- 
ment of  the  wound  itself,  and  partly  by  the  application  of  aseptic  principles 
in  the  introduction  of  the  sutures,  or  the  employment  of  other  retentive  means. 

Formerly  the  existence  of  contused  wound  edges  was  considerefl  a  con- 
traindication to  the  use  of  sutures.  If  the  requirements  of  a  rigid  asepsis  or 
antisepsis  are  met,  however,  it  is  possible  to  obtain  primary  union,  even  in 
these  cases.  But  if  the  crushed  tissues  are  beyond  the  hope  of  recovery, 
either  the  attempt  to  apply  the  suture  or  the  effort  to  secure  coaptation 
of  the  edges  otherwise  must  be  abandoned,  or  the  crushed 
tissues  must  be  first  removed. 

In  case  of  extensive  and  deep  wounds,  particularly 
those  which  have  been  accidentally  inflicted,  there  will 
probably  be  a  large  amount  of  wound  secretion,  and  drain- 
age must  be  provided  for.  A  fenestrated  drainage-tube  of 
rubber  may  be  passed  the  entire  length  of  the  wound, 
projecting  at  one  or  both  ends.  In  the  latter  case  the 
patency  of  the  tube  may  be  assured  by  "flushing"  with  a 
stream  of  antiseptic  solution  without  removing  the  tube 
until  it  is  permanently  withdrawn.  Finally,  accidentally 
inflicted  shallow  wounds  of  limited  area  may  be  drained 
by  means  of  a  twisted  strip  of  iodoform  or  other  sterile 
gauze.  The  large  majority  of  operation  wounds  made 
imder  proper  conditions  of  asepsis  may  be  closed  without 
drainage. 

The  protection  of  the  line  of  suturing  is  of  impor- 
tance.    This  is  usually  accomplished  by  means  of  a  simple 
gauze  dressing.     A  narrow  strip  of  silver  foil  affords  protec- 
tion, and  at  the  same  time  furnishes  the  base  for  antiseptic  compounds  formed 
by  the  action  of  the  wound  secretions  on  the  metal  (H  a  1  s  t  e  d). 

Gaping  of  the  wound  edges,  due  to  the  elasticity  of  the  tissues,  is  overcome 
by  permanent  coaptation.  In  order  to  accomplish  this,  more  or  less  strain  is 
placed  on  the  structures  sutured.  In  case  of  large  wound  defects  or  in  tissue 
naturally  unyielding  this  may  be  more  than  they  can  bear,  and  there  occurs  a 
"cutting  through"  of  the  tissues,  the  latter  being  forced  against  the  rigid  and 
unyielding  thread.  Separation  of  the  sutured  line  takes  place  and  the 
suture  material  becomes  buried  in  the  tissues.  This  may  also  happen  from 
tying  the  sutures  too  tightly  or  from  excessive  swelling. 

The  Interrupted  Suture. — This  consists  of  a  single  thread  passed  by 
means  of  a  needle  through  iDoth  wound  edges  and  then  tied,  the  latter  being 
at  the  same  time  adjusted  in  their  proper  relation  to  each  other  (Fig.  100). 
The  needle  emplo3'ed  may  be  either  curved  or  straight,  according  to  the  re- 
quirements of  the  case.  The  Hage  dorn  needle  (Fig.  101)  is  flattened  and  has  a 
22 


Fig.    100. — Inter- 
rupted Suture. 


322 


THE    GENERAL    PRINCIPLES    OF    OPERATIVE    TECHNIC 


lance-shaped  point .  The  wound  which  it  makes  lies  in  the  same  direction  as  the 
line  of  tension  when  the  sutm-e  is  tightened,  hence  its  edges  tend  to  come  together 
rather  than  gape,  as  is  the  case  when  the  ordinary  needle  is  used.  Practically, 
however,  any  well-polished  and  properh^  shaped  needle  will  answer  the  purpose. 
For  suturing  the  peritoneum  round  wire  needles  are  employed.  For  suturing 
other  soft  tissues,  needles  with  cutting-edges  are  used.     A  straight  needle  may 

be  employed  on  convex  portions  of  the 
body,  while  in  concave  portions  the 
curved  needle  is  more  useful.  As  a  rule, 
the  latter  can  be  used  in  both,  hence  this 
form  of  needle  is  most  freciuentty  em- 
ployed. The  curved  needle  may  have 
different  degrees  of  curvature,  those  rep- 
resenting from  one-third  to  two-thirds  of 
a  circle  being  most  commonh'^  used.  In 
addition,  needles  have  been  devised  for 
special  operations,  such  as  cleft  palate, 
etc. 

In  perforating  the  tissues  the  thumb 

and  finger  may  be  used  for  grasping   the 

needle,   or    preferably,    and     for    aseptic 

reasons,    one    of  the    many    varieties    of 

needle-holders  may  be  employed  (Figs.  102,  103).     The  needle  forceps  are 

particularly  useful  in  deep  sutures,  or  when  the  density  of  the  latter  is  such  as  to 

require  considerable  force  to  drive  the  needle  through  them. 

In  passing  the  needle  through  the  skin  surface  there  is  less  risk  of  conveying 
infection  to  the  depths  of  the  wound  if  the  perforation  is  effected  from  beneath 
to  the  surface,  instead  of  from  the  outer  surface  of  the  skin  on  one  side  and  from 


Fig.  101.— 1,  The  Hagedorn  needle;  2,  the 
Hagedorn  needle  modified  by  twisting 
so  as  to  permit  it  to  be  grasped  with  a 
hemostatic  forceps. 


Fig.   102. — Richter's  Needle-holder. 


beneath  on  the  other.  The  amount  of  infectious  material  in  the  substance  of 
the  skin  is  almost  incredible  (W  e  1  c  h),  and  passing  a  needle  from  the  surface 
into  the  wound  depths  favors  infection  of  the  latter.  In  passing  the  needle  in 
this  manner  it  is  convenient  to  place  a  needle  on  the  thread  at  both  ends;  and 
to  avoid  the  annoyance  of  having  the  second  needle  become  disengaged  from 
the  thread  while  the  first  is  in  use,  it  may  be  threaded  with  a  "  hitch"  or  bight 
(Fig.  104). 

Where  the  parts  to  be  united  consist  of  several   distinct  layers  of  tissue, 
as,  for  instance,  in  abdominal  section  in  which  peritoneum,  muscle  and  fascia. 


MECHANISM    OF    UXITIXG    THE    TISSUES 


323 


and  skin  are  to  be  united  each  to  its  own  structure  separately,  layer  sutures  are 
employed.  These  cannot  be  removed,  and  hence  are  called  buried  sutures. 
For  this  purpose  either  catgut  or  kangaroo  tendon  may  be  used.  These  are 
sometimes  prematurely  absorbed  and  permit  separation  of  the  suture  line. 
If  of  nonabsorbent  material,  they  may  become  a  source  of  irritation  to  the 
tissues.  The  employment  of  the  removable  layer  suture  obviates  these 
disadvantages.  With  the  thread  (crin-de-Florence  or  silkworm-gut  being 
preferred)  armed  with  a  needle  at  each  end,  each  layer  is  secured  separately 
by  passing  the  needles  from  the  depth  of  the  wound  toward  the  surface.  As 
each  successive  la^'er  is  included  in  the  loop  the  needles  are  reversed  as  regards 
position  before  being  passed  through  the  next  layer,  the  two  legs  of  the  suture 
crossing  each  other  between  the  separate  layers  until  the  skin  surface  is  reached 


Fig.   103. — The  Richter  Needle  Forceps  Modified. 
A,  The  cam  and  "pick-up"  device  shown  in  detail. 


(Figs.  105.  106,  107).  The  sutures  are  here  secured  in  pairs  by  "bolsters"  of 
rubber  tubing  (Figs.  108,  109). 

Buried  sutures  are  also  employed  to  obliterate  so-called  dead  spaces,  as, 
for  instance,  those  cavities  in  the  thick  fat  layer  of  the  abdominal  wall  of  very- 
obese  individuals  left  after  operations  for  the  radical  cure  of  ventral  or 
umbilic  hernia. 

For  accurately  coapting  the  skin  edges  either  the  interrupted  suture  or  the 
continuous  suture  may  be  used.  The  latter  may  be  employed  in  a  simple 
over-and-over  manner  (Fig.  110).  or  the  intracuticular  suture,  in  which 
the  needle  is  passed  on  the  raw  edge  of  the  skin,  parallel  to  it,  mav  be  used 
(Fig.  111). 

The  best  form  of  the  continuous  superficial  suture  is  the  chain-stitch. 
(Ford).     The  needle  is  passed  as  in  the  ordinary  interrupted  or  glover's 


324 


THE    GE:XERAL    PRI^XIPLES    OF    OPERATIVE    TECHXIC 


suture.     Instead  of  allowing  the  suture  to  cross  the  wound  edges  at  a  more  or 
less  acute  angle,  however,  the  needle  is  passed  beneath  what  would  ordinarily 


Fig.  104. — M  e  t  h  o  d 
OF  Securing  a 
Strand  of  Silk- 
worm-gut TO  THE 
Needle. 

The  end  of  the 
strand  which  has  been 
passed  through  the  eye 
of  the  needle  is  passed 
a  second  time  from  the 
same  side  as  at  first. 
The  resulting  "hitch " 
or  bight  is  then  drawn 
tight. 


Fig.  105. — The  Removable  Later  Suture. 
Method  of  application  with  one  needle.  Schematic,  represent- 
ing a  cross-section  of  the  abdominal  wall.  1,  1,  First  layer,  consist- 
ing of  skin,  fat,  and  superficial  fascia;  2,  2,  second  layer,  consisting 
of  transversalis  muscle,  and  transversalis  fascia;  .3,  .3,  third  layer, 
con.sisting  of  peritoneum ;  4  4,  4,  4,  dead  spaces  between  the  planes 
of  the  layers;  .5,  gap  representing  the  wound  to  be  closed;  the  end 
of  the  thread  at  .5  is  armed  -with  a  needle  and  finally  passed  through 
the  first  layer  at  6  from  within  outward  to  complete  the  suture. 


Fig.   106. — The  Re.movable  Layer  Suture. 
A  Simultaneous  coaptation  of  the  edges  and  plane  surfaces  of    the  layers  of  the  abdominal  wall ;  B, 
the  manner    of    passing    the    suture    ends  through    the    lumen    of    the    rubber    "bolster      when  thick- 
walled  tubing  is  employed. 


Fig.  107. — The  Removable  Later  Sutltre. 
Method  of  application  with    two  needles.      The   relative   position   of   the  needles   is   reversed  as 
each  layer  is  secured,  the  threads  crossing   each  other  as   this   is  done, 
taken  by  the  suture. 


The  arrows  show  the  directions 


MECHANISM    OF    UNITING    THE    TISSUES 


325 


Fig.  108. — The  author's  figure  of  8 
removable  layer  suture,  applied  to  the  oblique 
appendicitis  incision,  showing  the  sutures 
passed  through  all  the  layers,  including  the 
skin,  and  the  bolsters  in  position.  The 
dotted  lines  in  the  upper  right-hand  corner 
show  the  method  of  passing  the  suture 
through  the  lumen  from  each  end  of  the  bol- 
ster. 


Fig.  109. — The  author's  figure  of  8 
removable  layer  suture,  applied  to  the  ob- 
lique appendicitis  incision  sho^^-ing  the  su- 
tures drawn  sufficiently  taut  to  approxi- 
mate the  edges  of  the  incision  in  the  deep 
structures.  The  edges  of  the  skin  are 
shown  wider  apart  than  they  actually  occur, 
in  order  to  demonstrate  the  approximation. 


Fig.     110. — Continu- 
ous Suture. 


Fig.  111. — The  author's  figure  of  8 
removable  layer  suture,  showing  the  bolsters 
set,  the  sutures  tied,  and  the  skin  edges  in 
course  of  closure  by  the  intracutieular  suture. 


Fig.  112. — Continu- 
ous Chain-stitch 
(Ford's). 


326  THE    GENERAL    PRINCIPLES    OF    OPERATIVE    TECHNIC 

be  the  overlying  portion  and  the  stitch  (h-awn  taut  with  this  l_\'ing  j)arallel 
to  the  wound  edges.  The  needle  may  be  passed  one  or  more  turns  l)eneath  the 
loop.  Several  turns  should  be  made  at  the  termination  of  the  suture  line  in 
order  to  secure  the  suture  (Fig.  112).  (Special  sutures  will  be  descril)C(l  in  the 
part  on  Regional  Surgery.) 

Coaptation  by  Means  of  Adhesive  Plaster. — This  is  a  somewhat 
unsatisfactory  procedure,  only  the  superficial  edges  of  the  skin  being  brought 
together.  It  cannot  supplant  the  use  of  sutures,  though  it  is  sometimes  em- 
ployed as  a  substitute  for  superficial  sutures.  When  it  is  thus  used,  narrow 
spaces  should  be  left  between  the  strips  to  permit  the  escape  of  secretions  from 
between  the  skin  edges. 


SECTION  XI 
OPERATIONS  ON  INDIVIDUAL  STRUCTURES 

OPERATIONS  ON  THE  SKIN 
OPENING  OF  ABSCESSES 

Abscesses  may  arise  in  the  subcutaneous  connective  tissue,  or  mav  invade 
this  region  from  the  deeper  parts.  In  modern  surgical  practice  it  is  deemed  best 
to  empt}^,  curet,  and  otherwise  treat  antiseptically  suppurating  foci  as  soon  as 
their  presence  can  be  demonstrated.  This  may  involve  incisions  through 
fascia  and  muscular  structures,  as  well  as  through  the  skin. 

The  method  usually  employed  in  opening  an  abscess  of  the  sul^cutaneous 
connective  tissue  is  that  known  as  transfixion.  A  curved  pointed  bistour}'  is 
passed  with  its  edge  upward  through  the  abscess  cavity  and  the  incision  effected 
by  a  simple  stroke  outward.  By  this  means  the  length  of  the  incision  can  be 
governed  with  greater  certainty,  the  incision  is  made  with  greater  rapidity  and 
hence  is  less  painful.  Its  length  should  correspond  to  the  diameter  of  the 
abscess  cavity  if  the  latter  is  not  more  than  tw^o  inches  in  diameter.  After 
free  incision  vigorous  curettage,  thorough  antiseptic  irrigation,  and  "scour- 
ing" of  the  abscess  cavity  by  means  of  dry  aseptic  gauze  should  be  employed. 
In  an  abscess  of  more  than  two  inches  in  diameter  a  smaller  opening  or 
more  than  one  opening  (counter-opening)  may  be  made.  After  irrigation  and 
curettage  one  or  more  drainage-tubes  are  introduced.  In  making  a  second 
opening  the  edge  of  the  first  may  be  grasped  by  a  dissecting  forceps  to  steady 
the  collapsed  abscess  wall;  or  the  forceps  may  be  pushed  through  the  first  open- 
ing to  a  point  opposite,  the  blades  separated,  and  the  parts  thus  steadied  while 
the  second  incision  is  made.  A  finger  is  to  be  introduced  and  the  size  and  shape 
of  the  cavity  ascertained;  this  can  then  be  curetted  intelligently.  Antiseptic 
irrigation  can  be  carried  on  at  the  same  time  if  the  irrigating  curet  is  emploved 
(Fig.  94). 

When,  either  through  spontaneous  opening  of  an  abscess  or  through  an 
insufficient  artificial  opening,  the  drainage  is  incomplete,  this  should  be  reme- 
died by  introducing  a  probe-pointed  bistour^^  through  an  already  existing 
opening  and  withdrawing  it  vertically,  at  the  same  time  enlarging  the  opening. 
The  abscess  cavity  should  then  be  treated  as  if  now  opened  for  the  first  time. 
Undermined  portions  of  skin  should  be  opened  up  freely,  and  in  some  instances 
may  be  excised  with  advantage. 

PLASTIC  OPERATIONS  ON  THE  SKIN 
Plastic  operations  are  resorted  to  for  the  purpose  of  artificially  restoring 
lost  portions  of  the  body  by  means  of  living  tissues.     The  skin  forms  the  most 
essential  material  for  plastic  operations  on  the  surface  of  the  body,  by  reason 
of  its  rich  supply  of  arteries  and  capillaries. 

327 


328  OPERATIONS    ON    INDIVIDUAL    STRUCTURES 

Heteroplastic  operations  consist  in  replacing  defects  by  means  of  tissue 
derived  from  sources  other  than  the  intUvidual  in  whom  the  defect  occurs. 
This  includes  transplantation  from  man  to  man,  or  from  a  lower  animal  to  man. 
Attempts  in  this  direction  are  sufficiently  encouraging  to  justify  a  still  further 
trial  of  the  method. 

Autoplastic  operations  consist  in  replacing  defects  by  means  of  tissue 
taken  from  the  same  individual.  They  are  indicated  in  defects  resulting  from 
(1)  congenital  cleft  formations  (harelip,  cleft  cheek,  palatal  fissures,  exstrophy 
of  the  bladder,  etc.;  (2)  injuries;   (3)  thermic  and  chemic  destructive  action; 

(4)  chronic  ulcerative  processes,  particularly  those  arising  from  varicose  veins; 

(5)  the  removal  of  diseased  conditions  (carcinoma,  lupus,  syphilitic  and  tul)er- 
culous  ulcerative  processes);  (6)  the  removal  of  benign  tumors,  angiomas, 
etc. ;  (7)  cicatricial  displacement  leading  to  disturbances  of  shape  and  function 
of  parts. 

The  indications  may  be  further  divided  into  those  of  a  cosmetic  and  those 
of  a  functional  character.  It  may  happen,  as  in  the  case  of  ectropion  of  the 
eyelid,  that  both  cosmetic  and  functional  considerations  enter  into  the  question. 
In  the  case  of  injuries  the  plastic  replacement  should  be  attempted  at  once  by 
means  of  the  part  which  has  been  removed.  Portions  of  the  nose,  fingers,  the 
tongue,  etc.,  should  be  immediately  replaced  and  sutured   in  position.     The 

ends  of  the  middle  and  ring  fingers  have 
I      been  successfully  replaced  seven  hours 

»:      after  they  had  been  cut  off  (F  i  n  n  ey). 
In  case  the  injury  is    accompanied  by 
;      more  or  less  crushing  or  other  destruc- 
tion of  the  parts,    replacement    cannot 
be  successfully  accomplished. 

^  (Plastic  operations  will  be   further 

Fig.  113.-RELAXING  Incision.  discussed  in  Regional  Surgery.) 

In  ulcerative  processes  from  syph- 
ilis, tuberculous  disease,  etc.,  the  local  focus  must  be  first  healed.  In  carcin- 
omatous and  other  tumors  in  w^hich  the  diseased  tissues  have  been  removed, 
the  plastic  operative  measure  best  adapted  to  the  case  may  be  proceeded  with 
at  once. 

General  Methods  of  Plastic  Operations. — Two  essential  methods  are 
employed.  The  first  consists  in  the  utilization  of  tissues  from  the  immediate 
neighborhood;  the  second  in  their  transplantation  from  a  distant  part.  The 
first  may  be  again  divided  into  those  methods  in  which  the  tissues  used  to 
replace  the  defect  are  brought  into  position  by  sliding  or  lateral  displacement, 
and  those  in  which  flap  formation  and  torsion  of  the  pedicle  are  distinguishing 
features. 

Replacement  by  means  of  lateral  displacement  may  sometimes  be  ac- 
complished without  the  introduction  of  new  tissue.  This  may  be  aided  by  the 
loosening  of  the  skin  structures  by  means  of  a  dissection  carried  along  the  plane 
of  the  subcutaneous  connective-tissue  space,  or  by  the  employment  of  relaxing 
incision  (Fig.  113)  made  parallel  to  the  intended  line  of  sutures,  or  by  both. 
The  gaps  left  by  these  relaxing  incisions  are  permitted  to  heal  by  granulation. 
A  method  of  closing  a  rectangular  shaped  defect  is  shown  in  Fig.  104.  D  i  e  f  - 
fen  bach's  procedure  for  closing  a  triangular  shaped  defect  is  shown  in  Fig. 


OPKKA'l'IONS    ON    THE    SKIN 


329 


115.     Tlu>    motluxl    of    DiMTrnbaeh  avus    improved  by   B  ii  r  o  w   (Fig. 

^^*  Flap  Formation  with  Torsion.-The  advantages  of  this  method  are  as 

follow.      (1)  it  adn.itsof  ahnost  universal  apphcation;    (2)  the  flaps  can  be 

0  ace uratelv  adapted  to  the  defects;    (3)  tissue  free  from  disease  can  be 


Fig.    114.— Closing  Kect.vngul.vk  Gat. 

selected  for  the  purposes  of  the  repair;  (4)  by  proper  care  in  Pl-^f  |;^  P^^^^^^^^^^ 
the  nutrition  of  the  parts  may  be  more  certainly  assured.     When  the    rans 
planted  portion  is  takenfrom  a  distant  part,  the  former  is  approximated  to  the 
place  of  defect;  under  these  circumstances  torsion  of  the  pedicle  may  or  may 
not  be  employed. 


▼7  \^T' 


Fig.  115. — Closing  Triangulak  Gap. 

The  free  transplantation  of  large  flaps  dissected  from  the  skin  and  subcu- 
taneous tissue  is  occasionaUy  employed.    There  is  a  greater  habihtr  of  death 

of  the  flans  in  this  method.  ,  ,     i     ,■   i  •  i  • 

Death  of  transplanted  portions  is  less  likely  to  follo,v  the  method  ot  shdmg 
than  any  other.     In  flap  operations  mth  torsion  the  flap  must  be  sufhciently 


Fig.   116.— Burg w's  Modification  of  Dieffenbach' 


Method. 


narrow  else  the  twist  ^vhich  it  receives  may  result  in  undue  pressure  on  the 
ve  sT'ot  supply  and  the  occlusion  ot  them.  The  most  '"n^rtant j^ec^utron. 
are  the  following:  (1)  The  pedicle  is  to  be  situated  m  a  ^-eg-on  ><>-  "^^^ 
supply  of  vessels  pass  to  the  portion  to  be  transplanted;  (2)  the  formation  of 


330  OPERATIONS    OX    INDIVIDUAL    STliUCTURES 

the  flap  must  be  accomplished  with  the  greatest  care,  the  edge  of  the  scalpel 
being  directed  awcaj  from  the  skin,  particularly  when  dissecting  near  the 
pedicle  itself,  in  order  not  to  injure  the  vessels  in  the  latter;  (.3)  an  accurate 
isolation  of  the  pedicle  is  necessary,  in  order  to  permit  torsion  without  folding; 
(4)  the  stem  must  be  sufficiently  long  to  permit  an  easy  twist.  The  last  is 
further  provided  for  by  extending  the  incision  which  marks  one  boundary  of  the 
pedicle  somewhat  further  than  the  incision  which  marks  the  other  Ijoundary, 
so  that  there  is  a  long  and  short  edge  to  the  pedicle,  the  long  edge  representing 
the  edge  from  which  the  twist  is  turned.  The  raw  surface  of  the  flap  must 
fit  closely  on  the  properly  prepared  surface  of  the  defect,  and  the  edges  of  the 
former  are  to  be  accurately  sutured  to  the  latter.  If  the  transplanted  portion 
is  intended  to  replace  cicatricial  tissue,  the  latter  must  be  dissected  entirely 
away,  in  order  to  obtain  a  normally  vascularized  surface  for  the  reception  of 
the  flap.     Aseptic  measures  must  be  employed. 

Plastic  procedures  are  most  successful  when  there  is  a  rich  supply  of 
arterial  and  capillary  vessels,  as,  for  instance,  in  the  facial  region.  In  regions 
in  which  the  vessels  are  less  plentifully  supplied  it  is  sometimes  of  advantage 
to  loosen  the  flaps  from  the  subcutaneous  connective  tissues,  and  they  are  thus 
nourished  by  a  pedicle  at  each  end,  gauze  dressing  or  oiled  silk  protective  being 
packed  beneath  it.  At  the  end  of  a  week  or  when  a  profuse  granulating  surface 
has  been  obtained  one  of  the  pedicles  is  severed  and  the  edges  of  the  flap  and 
defect  are  freshened.  This  is  called  transplantation  of  a  granulating  flap. 
It  is  sometimes  employed  in  operations  for  exstrophy  of  the  bladder. 

Elastic  and  cicatricial  shrinkage  of  the  flap  invariably  occurs.  The 
former  takes  place  at  once  and  amounts  to  about  one-third  of  the  entire 
area  of  the  flap.  It  is  to  be  compensated  for  by  an  increase  in  the  dimensions 
of  the  transplanted  portion  over  the  size  of  the  defect.  Cicatricial  shrinkage 
is  to  be  guarded  against  by  bringing  the  raw  surfaces  as  accurately  as  possible 
into  opposition,  so  that  primary  union  rather  than  the  filling  of  an  intervening 
space  by  granulation  is  thereby  secured.  In  rhinoplasty  the  newly  formed  part 
must  at  first  be  largely  in  excess  of  the  original,  in  order  to  allow  for  the 
shrinkage  which  occurs  in  the  course  of  a  few  months. 

Secondary  shrinkage  of  the  flap  is  prevented  to  a  great  extent  by  reinforc- 
ing the  latter  by  means  of  the  cicatricial  tissues  about  the  defect.  For  instance, 
in  the  case  of  a  defect  of  the  anterior  portion  of  the  nose,  the  skin  at  the  root 
of  the  latter  is  circumscribed  by  a  horseshoe-shaped  incision,  loosened  and 
turned  downward,  its  wound  surface  corresponding  to  that  of  the  flap  taken 
from  the  forehead  (see  page  510). 

The  underlying  periosteum  may  sometimes  be  employed  as  a  portion  of  the 
transplanted  structures.  In  the  operation  of  uranoplasty  this  is  imperative 
(L  a  nge  nb  e  c  k),  and  also  where  cicatricial  tissue  must  be  utilized,  the 
vessels  between  the  cicatrix  and  the  periosteum  being  carried  along  with  the 
flap. 

The  flap  should  empty  itself  of  blood  before  it  is  sutured  in  place.  This 
prevents  the  formation  of  coagula  which  tend  to  retard  the  new  circulation  in 
the  flap.  A  pale  flap  is  more  favorable  than  a  congested  one.  In  the  former  the 
supply  of  blood  will  probably  be  reestablished  in  a  few  hours;  in  the  latter, 
retarded  return  flow-  and  stasis  quickly  threaten  the  integrity  of  the  flap. 

The  restoration  of  normal  conduction  of  sensation  occurs  in  the  course  of 


OPERATIONS    ON    THE    SKIN 


331 


time,  though  at  hrst  the  sensation  nia}-  be  referred  to  the  jDoint  from  which 
the  transplanted  portion  was  taken. 

Reverdin's  Method. — This  consists  in  the  implantation  of  complete^ 
se})a rated  small  Hat  portions  of  epidermis  which  form  islands  on  the  granulating 
stirface  of  the  defect.  These  soon  become  sttrrounded  by  a  zone  of  proliferat- 
ing epithelium.  The  transplanted  epidermis  is  not  very  durable.  The  outer- 
most layer  is  cast  off,  giving  every  appearance  of  failure,  yet  sufficient  epithelial 
structtire  remains  from  which  further  proliferation  occurs  until  the  entire  sur- 
face is  covered.  The  fla])s  should  be  of  skin  only  and  not  more  than  three- 
eighths  of  an  inch  in  diameter.  If  larger  pieces  are  used  they  should  be  elliptic 
shaped  in  order  better  to  close  the  defect.  Still  smaller  pieces  may  be  obtained 
by  picking  up  a  fold  of  the  skin  with  mouse-tooth  forceps  and  snipping  them 
off  with  scissors;  a  large  number  of  these  may  be  scattered  over  the  surface 
of  the  defect.     A  special  instrument  may  be  employed  (Fig.  117). 

Autoepidermic  Skin=grafting. — This  may  be  employed  to  fill  in  an 
ulcerateil  surface  or  a  defect  in  which  repair  is  under  way  by  granulation. 
The  method  is  based  on  the  fact  that  the  newly  developed  epithelial  cells  are  very 
active  in  growth  at  the  edges  of  a  granulating  ulcer  or  defect.  The  surface 
to  be  grafted  is  prepared  by 
gentle  curetting  where  the 
granulations  are  weak  and 
flabby ;  hemorrhage  is  arrested 
by  firm  pressure.  The  thin 
blue  line  of  epithelial  cells  that 
has  formed  along  the  edge  of 
the  defect  is  dissected  up  and 
small  pieces  about  one-eighth 
of  an  inch  square  cut  off  and 
placed  with  their  raw  surfaces 
clown  on  the  granulating  sur- 
face. The  operation  is  pain- 
less. Each  graft  is  covered  with  a  small  piece  of  oiled  silk  and  dry  sterile 
gauze  dressing  is  applied  (j\I  c  C  h  e  s  n  e  y). 

Thiersch's  Method. — This  consists  in  shaving  long  strips  of  the  thick- 
ness of  only  a  portion  of  the  skin  from  the  outer  surface  of  either  the  arm  or  the 
thigh,  preferably  the  latter,  b}'  means  of  a  razor,  and  transferring  these  directly 
to  the  surface  prepared  for  their  reception.  It  is  applicable  alike  to  chronic 
ulcerated  surfaces  and  to  defects  left  after  the  removal  of  large  tumors,  par- 
ticularly those  of  the  breast.  In  the  case  of  the  former,  the  granulating  surface 
should  be  brought  into  as  health}'  a  condition  as  possil^le.  In  the  case  of  the 
latter  aU  hemorrhage  must  be  arrested  before  the  grafts  are  placed  in  position. 
The  grafts  must  be  of  uniform  thickness  and  have  even  edges,  in  order  that  there 
may  be  no  gaps  between  for  cicatricial  tissue  to  form.  Parallel  incisions  mark- 
ing the  lateral  boundaries  of  the  strips  to  be  taken  may  be  made  from  one  to 
two  inches  apart,  according  to  the  reciuirements  of  the  case,  these  passing  onlv 
partly  through  the  skin.  The  skin  is  now  put  on  the  stretch.  (Figs.  118  and 
119.)  Pressure  by  some  hard  substance  on  the  skin  surface  just  in  advance  of 
the  razor  sometimes  answers  a  good  purpose.  In  the  case  of  the  arm,  the  sur- 
geon's hand  encircling  the  parts  will  make  sufficient  tension.     The  strips  are  cut 


Fig.  117. — Combixed  Mouse  tooth  Forceps  and  Scis- 
sors FOR  SkIX-GKAFTIXG  AFTER  MeTHOD  OF  ReVER- 
DIX. 


332 


OPERATIONS    ON    INDIVIDUAL    STRUCTURES 


by  a  sawing  movement  of  the  razor,  held  flatwise.  'Fhe  field  of  operation  should 
be  kept  moistened  with  a  sterilized  normal  salt  solution;  no  antiseptics  are  used. 
The  grafts  are  applied  at  once  to  the  defect  or  ulcerated  surface,  care  being 
taken  that  their  edges  do  not  roll  under,  and  are  covered  with  strips  of  sterilized 
oiled  silk  protective  arranged  in  "basket  strapping"  fashion,  with  narrow 
intervening  spaces  for  drainage  (Fig.  120).  Gauze  dressings  wrung  out  of  the 
sterilized  normal  salt  solution  are  applied  and  this  is  again  covered  with  pro- 
tective or  rubber  tissue;  a  layer  of  cotton  and  a  roller  bandage  complete  the 
dressing. 


Fig.   118. — McBurxey's  Skin-stretching  Hooks. 

The  dressings  should  be  changed  in  from  one  to  three  days.  If  any  portions 
of  the  grafts  have  perished,  they  should  be  trimmed  away  with  sharp  scissors 
in  order  to  prevent  infection  of  the  remainder.  Moist  dressings  are  to  be 
reapplied  at  intervals  of  forty-eight  hours  until  healing  takes  place. 

The  success  of  the  method  depends  mainly  on  obtaining  grafts  of  even 
thickness  and  with  clean-cut  edges,  rendering  the  parts  from  which  these  are 
taken,  as  well  as  the  surface  to  which  they  are  to  be  applied,  aseptic,  and 


Fig.   119. — Cutting  a  Skix-guaft. 

securing  firm  contact  betw^een  the  surface  of  the  grafts  and  that  of  the  ulcer, 
with  no  blood  between;  finally,  on  the  early  removal  of  such  portions  of 
grafts  as  fail  to  take. 

The  Oilier  method  of  skin  grafting  differs  from  that  of  Thiersch  in 
that  the  former  aims  to  obtain  a  graft  as  thick  as  possible  without  including 
the  subcutaneous  tissue,  while  the  latter  makes  the  graft  as  thin  as  possible.  All 
fat  must  be  carefully  removed  from  its  raw  surface.     Its  area  must  be  at  least 


OPERATIONS   ON    THE    SKIN 


333 


one-sixth  larger  than  the  surface  to  be  covered,  and  in  adjusting  it  in  place,  its 
edges  must  l)e  accurately-  coai)tated  to  the  raw  edges  of  the  defect.  No  sutures 
are  emplo>'ed.     'ilie  parts  are  dressed  with  moist  dressings. 

The  After = treatment  of  Plastic  Operations.— An  irrigating  fluid 
should  be  cmpkn'od  which  does  not  coagulate  the  albuminous  substances  on  the 
surface  of  the  flap  or  defect.  A  0.6  per  cent  solution  of  sodium  chlorid  answers 
the  purpose  best.  Dressing,  as  well  as  gauze  sponge  material  employed  about  the 
operation,  should  be  wrung  out  of  the  same.  The  site  of  the  operation  should 
be  carefully  covered  in  by  narrow  strips  of  oiled  silk  protective,  arranged  as  in 
"basket-strapping"  (page  332).  Over  this  is  placed  a  goodly  supply  of  aseptic 
gauze,  and  the  whole  covered  with  sterilized  cotton  and  held  in  place  by  a 
roller  bandage.     On  redressing,  after  three  to  five  days,  care  should  be  taken 


llllllilili 

llilllllli 

llllllilili 

llllllilili 

lllllilll 

llllllilili 

■ 

■ 

II 

f 

■I 

1 

hiiiiiiin 

■ 

j= 

■ 

i 

miiiiin 

II 

1 

iliriiiip 

■ 

1 

^^^^H 

Fig.   120. — Basket  Strapping  Dressing  for  Skin-grafting. 

not  to  disturb  the  transplanted  portions  of  tissue.  The  moist  dressing  should 
be  continued  and  changed  every  second  or  third  da}'.  False  or  cicatricial 
keloid,  which  sometimes  develops  between  the  flaps,  is  said  to  be  prevented  by 
keeping  up  moist  dressings  until  the  healing  is  completed  (^I  c  B  u  r  n  e  y  )  . 


THE  REMOVAL  OF  TUMORS  OF  THE  SKIN 
Those  having  a  narrow  base  or  pedicle,  particularly  when  small  or  of  but 
moderate  size,  are  best  removed  by  putting  the  pedicle  or  base  on  the  stretch 
and  severing  with  the  curved  scissors.  Some  nevi  pigmentosi  may  be  treated 
in  the  same  manner.  Cauterization  of  warts  and  nevi  is  now  an  obsolete 
procedure. 

Congenital   capillary   and    capillar}^  venous  tumors  are  best  treated  by 
extirpation  with  the  knife.      The    hemorrhage  requires  special  care  in  its 


334 


OPERATIONS    ON    INDIVIDUAL    STRUCTURES 


management.  The  dilated  veins  usually  reach  through  the  sul)cutaneous  con- 
nective tissue  to  the  fascia,  and  it  is  therefore  best  to  carry  the  incisions  directly 
to  the  latter  structures.  The  vessels  leading  to  the  diseased  portion  should  be 
grasped  by  the  fingers  of  an  assistant  and  held  until  secured  by  the  hemostatic 
forceps. 

Ligation  of  the  base  may  be  combined  with  extirpation.     The  employment 

of  the  ligature  alone  is  objectionable  on  the  score  of  excessive  pain  and  sepsis. 

Small  angiomas  may  be  destroyed  by  means  of  the  thermocautery,  or  the  gal- 

vanocautery  loop.     The  platinum  wire  of  the  latter  is  led  around  the  base  in 

the  subcutaneous  connective   tissue  as  an  encircling  suture. 

Small  angiomas  also  maybe  attacked  by  electrolysis.     This  is 

accomplished  by  passing  needles,  insulated  for  a  greater  or 

lesser  distance,  into  the  tumor  in  a  direction  parallel  to  the 

surface  and  attaching  these  to  the  poles  of  a  galvanic  battery, 

the  current  being  allowed  to  pass  through  them;  or  one  needle 

may  be  employed,  the  other  pole  of  the  battery  being  attached 

to  a  sponge  electrode  placed  in  the  neighborhood.     To  save 

repeated  puncture  with  a  single  needle,  a  number  of  these  may 

be  fastened  to  a  handle  (Fig.  121)  to  which  is  attached  a  wire 

connected  with  the  l^attery. 

The  method  by  the  injection  of  water  at  a  high  tem- 
perature for  the  obliteration  and  cure  of  vascular  non- 
malignant  neoplasms  consists  of  the  injection  of  water  at 
a  temperature  of  from  190°  to  212°  F.,  or  sufficiently  hot  to 
coagulate  the  blood  and  the  albuminoids  of  the  tissues 
( W  y  e  t  h) .  A  metal  syringe  is  employed  and  the  amount  of 
water  used  and  the  temperature  are  governed  by  the  character 
and  size  of  the  growth,  and  by  its  situation.  Capillary 
nevi,  or  "mothers'  marks,"  should  receive  small  injections 
under  slight  pressure  and  at  a  temperature  not  above 
190°  F.  Care  should  be  taken  not  to  scald  the  skin.  A 
slight  blanching  of  the  latter  in  the  area  of  each  injection 
suffices  and  is  a  signal  in  all  cases  to  cease  at  once  injecting 
in  that  area.  The  injections  are  repeated  at  intervals  of  a 
week,  according  to  the  effect  produced.  In  cirsoid  aneurism 
and  large  cavernous  nevi  the  water  should  be  kept  at  the 
boiling-point,  and  large  quantities  (up  to  five  or  six 
ounces  in  some  instances)  used.  A  general  anesthetic  is  necessary.  Peripheral 
compression  should  be  used  to  prevent  embolism. 

Vaccination  of  an  angioma  is  a  very  uncertain  procedure;  the  injection  by 
means  of  perchlorid  of  iron  solution  is  mentioned  only  to  be  condemned. 

Venous  angiomas  or  cavernous  tumors  are  best  circumscribed  by  incision 
and  are  rapidly  extirpated.  Varices  are  treated  of  on  page  100  and  cirsoid 
aneurism  on  page  94. 

Atheromatous  cysts  or  wens  may  perforate  the  skin,  either  through  a 
suppurative  process  or  otherwise,  atheromatous  fistulas  resulting.  The 
suppurative  form  may  result  in  epithelial  carcinoma.  In  extirpating  these 
cysts  care  should  be  taken  to  preserve  the  sac  intact  in  order  to  facilitate  its 
entire  removal.     A  horseshoe-shaped  incision  should  be  made  well  beyond  the 


Fig.   121. — Steven- 
son's        Instru 

MENT     FOR     ElEC 
TROLYSIS. 


OPERATIONS    ON    THK    SKIN  335 

limits  of  the  tumor,  partially  surrounding  the  same.  B}^  turning  up  the 
jioi'tion  of  skin  inclosed  in  the  incision  as  a  flap  to  which  the  tumor  is  at- 
lacluHl  the  entire  growth  may  be  dissected  from  the  flap  and  the  latter  replaced. 

Congenital  dermoid  cysts  may  be  dealt  with  in  the  same  manner.  In 
these  cases  a  deeply  placed  i)edicle  is  often  found  containing  the  \'essels  of 
supply. 

Lipomas  are  extirpated  by  two  converging  incisions  (elliptic  incision).  In 
some  localities,  e.  g.,  the  neck  and  shoulders,  these  growths  cannot  be  dis- 
tinctl,v  defined  and  the  removal  must  be  more  or  less  arbitrary.  The  sim])le 
character  of  these  tumors  should  not  impel  the  surgeon  to  relax  his  ^-igilance  in 
the  application  of  aseptic  measures,  for  the  reason  that  erj^sipelatous  inflam- 
mation is  particularly  lial^le  to  follow  their  removal. 

In  elephantiasis  arabum  excision  of  the  hypertrophic  portions,  when 
possible,  is  preferable  to  the  long  incision  formerly  emplo}-ed.  ^Vhen  the 
scrotum  is  the  part  attacked,  extirpation  may  be  indicated.  Amputation 
should  be  reserved  for  cases  in  which  an  extensive  and  incurable  ulceration  is 
present,  or  suppuration  of  a,  large  joint  occurs. 

Malignant  Tumors  of  the  Skin. — Three  absolutely  positive  indica- 
tions always  exist  and  must  be  rigidly  followed  in  operating  for  these  growths: 
(1)  The  operation  must  be  performed  as  early  as  possible;  (2)  the  extirpation 
must  be  as  complete  as  possible;  (3)  the  next  adjacent  lymphatic  glands,  if 
it  is  possible  to  identify  them,  must  be  removed  at  the  same  operation. 

As  to  the  first:  In  cases  of  doubt  it  is  better  to  remove  an  innocent  tumor 
than  to  permit  the  development  of  advanced  carcinoma.  As  to  the  second: 
Thorough  extirpation  demands  the  free  use  of  the  knife,  rather  than  caustic 
applications.  The  most  deplorable  errors,  as  well  as  the  most  common  on  the 
part  of  the  practitioner,  consist  in  the  occasional  touching  of  commencing  epith- 
elioma of  the  skin  with  nitrate  of  silver.  Should  the  prejudices  of  the  patient 
prohibit  the  employment  of  the  knife,  the  use  of  the  Paquelin  cautery 
offers  the  next  best  means  at  our  command.  Pastes  of  zinc  chlorid,  arsenic, 
etc.,  are  occasionally  successfully  employed.  A  removal  or  destruction  of 
all  the  diseased  tissue,  together  with  half  an  inch  or  more  of  surrounding 
healthy  tissue,  constitutes  the  only  means  of  avoiding  recurrence  of  the  disease. 
As  to  the  third:  Unfortunately,  when  secondary  glandular  involvement  is 
present  in  carcinoma,  the  prognosis  is  exceedingly  unfavorable.  ]\Iany  of  the 
diseased  lymphatic  glands  are  so  deeply  situated  as  to  escape  recognition  and 
extirpation.  Every  swollen  gland  in  the  neighborhood  should  be  removed. 
Diligent  search  should  be  made  for  diseased  Ij^mphatic  glands  deeply  situated. 

In  late  cases  and  in  persistent  regionary  recurrences  operative  procedures  of 
a  purely  palhative  character  are  justifiable.  There  is  a  limit  to  these,  however, 
particularly  where  great  risk  to  life  is  involved.  But  curettage  and  energetic 
antiseptic  treatment,  including  the  use  of  the  thermocautery,  or  of  a  10 
per  cent  solution  of  zinc  chlorid,  followed  by  dusting  with  iodoform  to  meet 
the  indications  of  hemorrhage  and  sepsis,  are  almost  always  justifiable. 

The  above  remarks  apply  likewise  to  other  forms  of  malignant  disease  of  the 
skin,  particularly  that  exceedingly  malignant  form  known  as  melanotic 
sarcoma. 


336 


OPERATIOXS    OX    IX DIVIDUAL    STRUCTURKS 


OPERATIONS  ON  BLOOD-VESSELS 
THE  ARREST  OF  HEMORRHAGE 

Hemorrhage  is  distinguished  according  to  its  source  as  arterial,  venous,  and 
capillary  or  parenchymatous.  The  methods  employed  to  arrest  hemorrhage 
are  either  direct  or  indirect,  according  as  they  act  immediately  at  the  place  of 
bleeding,  or  through  distant  parts.  The  procedures  are  also  classified  as 
provisional  and  definite. 

The  importance  of  saving  as  much  blood  as  possible  during  operative 
procedures  is  verv'-  generally  recognized,  not  only  for  the  immediate,  but  for  the 
ultimate  prognosis.  On  the  completeness  with  which  all  bleeding  is  arrested 
before  the  wound  is  closed,  as  well  as  on  the  efficiency  of  the  measures  taken 
to  prevent  recurring  and  secondary  hemorrhage,  will  depend,  to  a  great  extent, 
prompt  healing  of  the  wound  and  rapid  recover}'  of  the  patient. 

For  spontaneous  arrest  of  hemorrhage  see  page  87. 

Provisional  measures  for  the  arrest  of  hemorrhage   are   indicated 


Fig.  122. — Petit's  Screw  Tourniquet. 


under  circumstances  where  means  and  appliances  for  its  definite  arrest  are  not 
at  hand,  or  where,  if  they  are  at  hand,  their  application  would  consume  valuable 
time  and  risk  the  patient's  life.  They  consist  in  procedures  having  for  their 
object  the  interruption  of  the  blood-current  between  the  heart  and  the  bleeding 
point.  This  is  accomplished  by  (1)  digital  compression ;  (2)  forced  positions 
of  joints;  (.3)  pressure  by  means  of  specially  contrived  apparatus  (arterial 
compressors,  or  tourniquets; . 

In  digital  compression  a  point  should  be  selected  where  the  artery  can  be 
pressed  against  a  bone.  In  the  lower  extremity  the  femoral  artery  can  be 
readily  pressed  against  the  horizontal  portion  of  the  pubic  bone  just  below 
Poupart's  ligament.  In  the  upper  extremity  the  brachial  arter\'  can  be  pressed 
against  the  humerus  along  the  inner  margin  of  the  biceps  muscle.  With  the 
arm  abducted,  the  axillary  artery  can  be  pressed  against  the  head  of  the 
humerus.  The  common  carotid  arterv^  may  be  pressed  against  the  carotid 
tubercle  (the  anterior  tubercle  of  the  transverse  process  of  the  sixth  cervical 


OPERATIONS   OX    T^T.OOD-VESSELS 


337 


A'ertebra).  In  this  latter  procedure,  however,  free  anastomosis  with  the  artery 
of  the  other  side,  as  well  as  with  the  subclavian  branches,  very  quickly  restores 
the  circulation  bej'ond  the  point  of  pressure.  The  radial  artery  may  be  pressed 
against  the  radius  and  the  posterior  tibial  against  the  inner  surface  of  the  os 
calcis.  In  thin  individuals  the  aorta  may  be  pressed  against  the  lumbar  ver- 
tebrae in  hemorrhage  from  the  internal  iliac. 

In  forced  jDositions  of  joints  the  arrest  of  hemorrhage  may  be  accomplished 
without  special  apparatus  and  without  anatomic  knowledge.  Extreme  flexion 
of  the  elbow-joint  and  of  the  knee- 
joint  will  bring  pressure  to  bear 
respectively  on  the  brachial  and 
popliteal  arteries.  H3'perexten- 
sion  of  the  hip-joint  will  bring  the 
femoral  artery  to  bear  strongly 
against  the  horizontal  ramus  of 
the  pubic  bone  so  as  to  ob- 
struct its  lumen  almost  ■  com- 
pletely. The  clavicle  may  be 
made  to  approach  the  first  rib, 
so  that  pressure  is  brought  on 
the  subclavian  artery,  by  ex- 
treme adduction  of  the  arm  to 
the  anterior  surface  of  the  thorax, 
and  at  the  same  time  the  acro- 
mion is  forcibly  crowded  down. 

Pressure  by  Means  of  Spe- 
cially Devised  Apparatus. — 
The  term  "toui'niquet"  is  now 
applied  to  all  apparatus  devised 
for  the  arrest  of  hemorrhage. 
The  old-fashioned  screw  tourni- 
quet (Fig.  122)  is  now  employed 
only  to  fulfil  special  indications 
(arterial  compressors  designed  for 
special  classes  of  cases  will  be 
treated  of  in  Regional  Surgery). 
The  Spanish  windlass  (Fig.  123)  is 
of  value  in  hemorrhage  from  the 
vessels  of  the  extremities,  from 
the  fact  that  it  may  be  readily  im- 
provised.    A  handkerchief  is  tied 

loosely  around  the  limb  and  a  stone  or  other  hard  object  is  placed  over  the 
A'essel  and  beneath  the  handkerchief.  A  cane,  bayonet,  sword,  scabbard, 
drumstick  or  similar  object  may  be  emploj^ed  to  twist  the  handkerchief 
until  the  bleeding  is  arrested.  The  pressure  is  l^rought  to  bear  on  veins, 
nerves,  and  lymphatics  as  well  as  on  the  artery,  and  for  this  reason  the  use  of 
the  windlass  should  not  be  long  continued. 

Bloodless  Operations  by  means  of  Esmarch's  Elastic  Compression. — 
This  is   applied   principally   to   the   extremities    and  is   intended   to    secure 
23 


Fig.  123. — Spanish  Windlass. 


338 


OPERATIONS   ON    INDIVIDUAL    STRUCTURES 


a  completel}^  exsanguine  condition  of  the  portion  to  be  operated  on.  The  limb 
is  elevated  for  a  few  minutes  in  order  to  empty  the  large  venous  channels  into 
those  of  the  tnmk  and  is  then  tightly  bandaged  in  a  spiral  manner  from  below 
upward  by  means  of  a  rubber  bandage.  The  turns  of  the  bandage,  with  the 
exception  of  the  first  two,  should  overlap  each  other  but  slightly  (Fig.  124). 
The  bandage  should  be  continued  some  distance  beyond  the  point  of  proposed 


Fig.    124. — Esmarcii's  Bandage  Applied. 
Showing  method  of  application  without  overlapping.     The  last  three  turns  serve  as  a  tourniquet. 

operation.  Here  a  few  circular  turns  of  the  bandage  are  made,  these  are  Hfted 
forcibly  away  from  the  limb  and  the  remaining  portion  of  the  roller  forced 
beneath  them  at  the  site  of  the  main  vessel  of  the  limb.  The  spiral  turns  are 
now  unwound,  at  a  point  conunencing  from  below  (Fig.  125).  A  tourniquet 
consisting  of   a  narrow  band  of  rubber  with   hook  and    chain  fastening  is 


Fig.   125. — Esmabch's  Bandage,  Showixg  Ease  of  Remov.vl  of  the  B.axdage. 

sometimes  employed  to  secure  the  vessels  immediately  alcove  the  termination 
of  the  bandage  before  removing  the  latter.  Ur  a  hard  roller  of  muslin  may 
be  laid  over  the  vessel  and  secured  bv  a  few  turns  of  the  rubber  bandage 
(Fig.  126). 

The  procedure  serves  only  a  temporary  purpose.     As  soon  as  the  constrict- 
ing band  is  removed,  not  only  does  the  blood  flow  from  the  larger  vessels,  but 


OPERATIONS    OX    BLOOD-VESSELS 


339 


there  is  a  relatively  greater  amount  of  parenchymatous  oozing.  This  is  due  to 
a  paralysis  of  the  muscular  aj^paratus  of  the  vessels  in  consequence  of  the  com- 
pression, which  is  complete  antl  continued  in  proportion  to  the  length  of  time 
the  compression  is  kept  uj).  It  may  therefore  happen  that  the  patient  loses 
as  much  blood  as  would  have  been  lost  if  no  preliminary  application  of  the 
rubber  bands  had  been  made.  Paralysis  of  an  extremity  has  also  been  charged 
to  the  use  of  E  s  m  a  r  c  h '  s  bandage  from  compression  of  nerve-trunks,  as 
well  as  sloughing  of  flaps  in  amputation  cases. 

In  spite  of  the  alleged  disadvantages  of  E  s  m  a  r  c  h  '  s  procedure  it  is 
of  great  value.  It  permits  rapid  operative  work,  particularly  in  seques- 
trotomies,  resections,  amputations,  etc.  Special  care  should  be  exercised  in  its 
application.  If  the  constricting  band  is  applied  too  loosely,  the  venous  return 
flow  is  interfered  with,  while  the  supply  of  blood  is  not  interrupted  ;  hence 
a  large  amount  of  venous  blood  msiy  be  lost.  On  the  other  hand,  a  too  tight 
constriction  endangers  the  nerve-trunks.  In  case  of  the  removal  of  a  large 
portion  of  the  body,  such  as  a  limb,  the  saving  of  blood  by  forcing  it  from  the 


Fig.   126. — Esmarch's  B.vxdage,  showixg  Hard  Roller  ix  Positiox  over  the  Vessel  axd  .Secured 

BY  THE  Last  Few  Turxs  of  the  Baxdage. 
The  roll  in  front  is  the  loose  bandage   unwound  from  the  limb,  gathered  in  a  roll,  and   placed  for  conve- 
nience of  disposition  beneath  a  few  loosely  applied  turns. 


limb  to  the  trunk  and  into  the  rest  of  the  circulation  constitutes  of  itself  a 
very  great  advantage. 

All  vessels  that  can  be  identified  should  be  ligated  before  the  removal  of  the 
constricting  band.  The  application  of  compresses  wrung  out  of  hot  water 
sen'es  to  check  the  capillary  hemorrhage. 

-  The  presence  of  malignant  disease,  putrefaction,  or  suppurative  conditions 
in  the  limb  is  a  contraindication  to  the  use  of  the  Es march  compression 
bandage.  Infectious  material  may  be  forced  into  the  lymph-vessels  in  this 
manner  and  distributed  over  the  entire  body. 

Prophylactic  Hemostasis. — This  may  be  obtained  by  (1)  digital  com- 
pression by  a  trained  assistant;  (2)  tourniquets  and  compressors  applied  from 
the  surface;  (3)  temporary  compression  through  an  open  wound  after  exposure 
of  the  vessel,  by  means  of  encircling  tapes  or  bands,  or  instruments  specially 
devised  for  the  purpose  (C  r  i  1  e) ;  (4)  preliminary  ligation  of  the  main  arterial 
trunk  (see  page  345). 


340 


OPERATIONS    OX    IXDIVIDUAL    STRUCTURES 


Permanent  Arrest  of  Arterial  Hemorrhage. — This  is  accomjjlishoil  by 
forcipressure,  followed  either  by  torsion  or  by  application  of  the  ligature. 
Under  certain  circumstances  it  may  be  necessary  to  rely  entirely  on  the  forceps. 

The  habits  and  fancy  of  the  operator  will  usually  govern  his  selection  of 
arterv^  clamps  or  hemostatic  forceps.  The  ring-handle  instrument  of  Pean 
and  its  modifications  are  employed  by  most  surgeons  (Fig.  127),  while  the  slide 
catch  or  torsion  forceps  are  preferred  by  others.  In  any  case  the  ends  of  the 
blades  or  jaws  should  be  so  shaped  as  to  permit  the  ready  sliding  of  the  loop 
of  the  ligature  therefrom.  The  forceps  should  be  loosened  and  removed  l^y  an 
assistant  before  the  first  portion  of  the  knot  is  fully  tightened,  in  order  that  the 


Fig.   127. — Varieties  of  Hemostatic  Forceps. 

constricted  portion  of  the  vessel  may  adapt  itself  in  shape  to  the  final  grasp  of 
the  ligature.  In  case  of  emergency  a  tenaculum  may  be  employed  to  lift  the 
bleeding  vessel  away  from  the  tissues.  If  this  method  is  used,  ligation  of  the 
vessel  must  at  once  foUow.  If  the  hemostatic  forceps  are  employed,  these  may 
be  left  until  the  close  of  the  operation. 

The  knot  may  be  the  usual  square  or  reef  knot;  a  "granny  knot"  with 
three  turns  serves  equally  as  well.  In  ligation  in  continuity  the  "  stay  knot" 
of  B  a  1 1  a  n  c  e    and   Edmunds    is  employed  (Fig.  1 28) . 

Ligature  Material. — Since  the  introduction  of  aseptic  surgery  catgut  has 
almost  entirely  replaced  silk  as  a  ligature  material.  Both  ends  are  cut  short 
and  buried  in  the  tissues.     The  ligature  material  is  destroyed  if  the  wound 


OPERATIOXS    ON    BI.OOD-VESSELS  341 

follows  an  aseptic  course,  living  tissue  being  proliferated  into  the  dead  but 
aseptic  substance  of  the  catgut.  If  septic  conditions  supervene,  the  ligature 
material  as  well  as  the  portions  of  tissue  constricted  may  be  cast  off.  Silk,  if 
only  the  smallest  or  finest  sizes  are  vised,  and  if  this  is  made  thoroughly  aseptic, 
may,  if  it  is  specialh^  desirable  to  employ  it  as  a  ligature  material,  also  be 
cut  short  and  left  in  the  tissues.  If  primary  union  is  obtained  its  presence  in 
the  tissues  may  do  no  harm  (Kocher,  Hals  ted).  Nevertheless  it 
remains  as  a  foreign  body,  and  hence,  as  a  ligature  material,  it  falls  short  of 
the  requirements  of  ideal  surgery. 

Torsion  may  be  sometimes  employed.  It  is  accomplished  by  grasping  the 
vessel  by  two  forceps  and  twisting  it  several  times  on  its  own  axis  between 
the  forceps.  The  lumen  is  closed  by  a  rolling  together  of  the  intima.  The 
method  is  applicable  only  to  the  smaller  vessels  and  has  been  but  little  used 
since  the  introduction  of  absorbable  ligatures. 

Acupressure  consists  of  pressure  exercised  on  the  vessel  l^y  means  of  a  long 
needle  passed  through  the  tissues.  The  procedure  has  practically  fallen  into 
disuse.  The  suture  ligature,  or  circumsuture,  is  employed  if  the  wounded 
vessel  is  situated  in  tissues  where  it  is  inaccessible,  as,  for  instance,  when 
a  vein  is  wounded  by  the  puncture  of  a  needle  in  suturing  a  wound,  or 
if  it  is  situated  in  tissues  from  which  the  points  of  the 
artery  forceps  repeatedly  slip  off.  A  full  curved  needle 
threaded  with  catgut  is  used.  This  is  passed  through 
the  tissues  in  which  the  bleeding  vessel  is  situated  and  at 
a  short  distance  from  the  latter,  in  such  a  manner  as  com- 
pletely to  circumscribe  the  vessel.  It  is  then  drawn  tightly 
and  secured  l^y  a  knot.  f^^  i28.-The  stay- 

Suture   of  Arteries. — In  the  case  of  small  wounds  of         ^^'o^    °^    ^^'^- 

LANCE      AND       Ed- 

large  arteries,  in  which  ligation  of  the  vessel  is  contrain-  munds. 

dicated,  the  opening  in  the  latter  may  be  sutured. 
A  round  intestinal  needle  and  fine  chromicized  catgut  should  Ije  used. 
All  the  coats  of  the  vessel  should  be  included  in  the  sutures.  A  second  row  of 
sutures,  including  the  sheath  and  the  overlying  tissues,  is  to  be  applied.  During 
the  operation  the  wounded  portion  of  the  vessel  should  be  kept  free  from  blood 
by  digital  compression.  The  contraindications  to  suture  of  arteries  are  (1) 
large  transverse  wounds  of  the  vessel;  (2)  lacerated  wounds;  (3)  contused 
wounds,  e.  g.,  gunshot  wounds.  An  atheromatous  condition  of  the  vessel  does 
not  necessarily  furnish  a  contraindication  to  the  procedure. 

Suture  of  the  arteries  is  not  likely  to  find  favor  among  practical  surgeons  for 
the  following  reasons:  (1)  Circumstances  rarely  arise  demanding  its  employ- 
ment to  the  exclusion  of  other  means  of  securing  hemostasis;  (2)  there  is  a  not 
unfounded  fear  of  thrombus  at  the  seat  of  injury;  (3)  the  dangers  of  aneurism 
due  to  subsequent  yielding  of  the  scar  in  the  vessel  are  not  to  be  lost  sight  of. 

Arterial  Invagination. — In  this  operation  the  proximal  end  of  the  artery 
is  invaginated  into  the  distal  end,  where  it  is  secured  by  firm  catgut  sutures 
(J.  B.  Murphy).  Temporary  occlusion  of  the  vessel  is  first  obtained. 
The  distal  end  of  the  artery  is  incised  longitudinally  for  a  short  distance  and 
the  sutures  are  preliminarily  applied  to  facilitate  the  invagination  (Fig.  129). 
The  method  may  be  used  in  cases  in  which  arterial  suture  is  contraindicated 
and  ligation  in  continuity  undesirable. 


342 


OPERATIONS    OX    INDIVIDUAL    STRUCTURES 


Arrest  of  Parenchymatous  Hemorrhage.— Simple  pressure  of  the  wound 
surface  by  accurate  suturin.ii;  and  the  ajiplication  of  dressing  usually  suffice 
to  arrest  this  form  of  bleeding.  Other  methods  consist  of  the  application  of 
compresses  wrung  out  of  hot  water,  or,  better  still,  hot  saline  solution.  Ice, 
ice-water,  or  the  ethyl  chlorid  spray  should  never  be  used  in  hemorrhage  com- 
plicated by  shock.  The  actual  cautery  long  antedated  the  use  of  almost  all 
hemostatics.  When  this  is  enijjloyed,  it  should  be  used  at  a  red  rather  than  a 
white  heat.  The  thermocauter^^  (page  316)  or  the  galvanocauter}^  (page  315) 
has  now  almost  entirely  replaced  the  cauter\'  irons  of  the  older  surgeons. 

Tamponade. — Continuous  oozing  of  blood  from  large  wound  surfaces,  and 
even  bleeding  from  vessels  of  considerable  size,  may  be  arrested  by  the  applica- 
tion of  an  antiseptic  tampon.  The  tampon  should  be  of  one  strip,  rather  than 
of  a  number  of  small  pieces,  in  order  to  avoid  overlooking  one  or  more  of  the 
latter  on  removal.  If  no  contraindication  to  its  use  exists,  e.  g.,  in  the  case 
of  children,  old  persons,  and  those  that  are  the  subject  of  renal  disease,  iodo- 
form gauze  may  be  freely  used.  Other^-ise  zinc  oxid  gauze,  or  even  plain 
sterile  gauze,  is  to  be  employed.  If  blood  finds  its  way  to  the  surface  the  pack- 
ing is  to  be  removed  and  replaced  by  fresh  gauze.  Unless  some  indication 
arises  for  its  removal  it  is  to  be  allowed  to  remain  fortv-eight  hours,  at  the  end 


Fig.  129. — Murphy's  Method  of  Arterial  Ixvagixatiox. 

of  which  time,  in  the  majority  of  cases,  the  bleeding  vessel  wiU  have  become 
obUterated.  If  oozing  persists,  the  bleeding  surface  may  be  moistened  for  a 
short  time  with  adrenalin  chlorid  solution,  1 :  1000,  and  repacked. 

If  the  bleeding  space  is  large  a  "  chemise  tampon"  may  be  employed.  This 
consists  of  a  spread  out  scpare  of  iodoform  gauze  of  sufficient  size,  to  the  center 
of  which  a  silk  ligature  is  secured  to  facilitate  its  removal.  This  is  spread  out 
on  the  wound  surface  and  the  pouch  thus  formed  is  tightly  packed  with  gauze. 
The  silk  ligature  is  brought  outside  and  the  projecting  ends  of  the  pouch  gath- 
ered up  and  secured  by  a  tape  or  narrow  strip  of  gauze. 

The  Graduated  Compress. — Where  the  bleeding  occurs  from  a  definite 
area  the  tampon  is  applied  in  the  shape  of  an  inverted  cone,  the  apex  of  which 
is  made  to  rest  on  the  bleeding  point.  Deep  suturing  by  means  of  the  buried 
catgut  suture  is  sometimes  of  use  in  the  arrest  of  otherwise  intractable  bleeding. 
A  round  needle  should  be  employed  in  order  not  to  provoke  further  hemorrhage, 
and  several  layers  of  sutures  may  be  applied,  if  necessary',  care  l^eing  taken  to 
include  any  bleeding  points  discoverable. 


OPERATIONS    OX    BLOOD-VESSELS  343 

Styptics. — Of  the  numerous  styptics  formerly  employed,  the  solution  of 
the  scsiiuiehloricl  of  iron  is  almost  the  only  one  now  used.  Even  this  is  more 
often  abused  than  rationally  employed.  The  iron  salt  incorporated  in  dry 
cotton  is  to  be  preferred  to  the  moist  application. 

The  active  principle  of  the  suprarenal  capsule  (adrenalin)  is  a  valuable 
local  hemostatic  agent.  It  is  employed  in  the  shape  of  adrenalin  chlorid  solu- 
tion, 1  :  1000.  Care  should  be  exercised  in  its  use,  since  the  l:)lanching  of  the 
tissues  is  marked  and  may  become  excessive,  leading  to  sloughing. 

Oil  of  turpentin  is  useful  as  a  styptic  after  excision  of  the  tonsils.  Fer- 
ripyrin,  a  combination  of  chlorid  of  iron  and  antipj^rin,  in  20  per  cent  solution 
has  recently  been  used  with  success  in  epistaxis  (J  u  r  a  s  z). 

Antipyrin  has  l^een  found  to  possess  valuable  hemostatic  as  well  as  anti- 
septic properties  (Park).  It  should  be  used  in  5  per  cent  solution. 
Gauze  wrung  out  of  this  solution  may  be  bandaged  on  bleeding  sur- 
faces or  packed  in  cavities  such  as  the  nasal  cavity.  It  may  also  be  used  in 
the  form  of  spra}'  with  an  atomizer. 

Hemorrhage  in  Hemophiliacs  or  "Bleeders." — The  surgeon  is 
occasionally  called  upon  to  operate  on  patients  who  are  the  subjects  of  hem- 
ophilia, as  well  as  to  arrest  hemorrhage  in  these  from  wounds  accidentally  in- 
flicted. In  addition  to  the  styptic  measures  already  mentioned,  inhalations  of 
carbon  dioxid  gas  and  the  internal  administration  of  calcium  chlorid  in  from 
30-  to  60-grain  doses  four  or  five  times  a  day  are  to  be  employed.  SaUne  infu- 
sion is  contraindicated,  but  copious  rectal  enemas  of  hot  saline  solution  should 
be  used.  When  the  bleeding  has  been  arrested  the  patient  should  be  placed 
on  a  nutritious  diet  and  preparations  of  iron,  such  as  Blaud's  mass,  or  the 
tincture  of  the  chlorid  should  be  given.  Operations  on  hemophiliacs  should 
be  avoided  as  much  as  possible,  and  when  not  absolutely  necessary  they  should 
be  postponed  for  a  few  days  to  permit  the  preliminary  administration  of  calcium 
chlorid. 

Arrest  of  Venous  Hemorrhage. — Bleeding  from  veins  as  well  as 
from  arteries  occurs  in  the  larger  operations.  The  dread  formerly  entertained 
of  the  occurrence  of  suppurative  phlebitis  after  ligation  of  large  veins  has 
entirely  given  way  to  the  confidence  felt  in  aseptic  and  antiseptic  measures. 
Whenever  venous  channels  are  opened  during  operation,  they  may  be  ligated 
with  the  same  confidence  as  in  the  case  of  arteries. 

The  necessity  for  ligation  of  veins  arises  more  frequently  in  operations  on 
the  lower  extremity  than  elsewhere,  owing  to  the  fact  that  numerous  varices 
are  here  present;  in  amputations  particularly,  dilated  veins  are  found  in  the 
muscular  structures.  Simple  pressure  in  cases  of  superficial  veins,  when 
wounded,  will  generally  arrest  the  hemorrhage,  e.  g.,  rupture  of  varicose  veins. 
A  compress  and  a  well  applied  bandage  usually  fulfil  the  indications  in  these 
cases. 

Air  Embolism. — In  the  anterior  region  of  the  neck  special  dangers  may 
arise  from  injuries  to  the  veins,  particularly  to  the  external  jugular.  This 
danger  refers  to  the  aspiration  of  air.  This  may  occur  likewise  in  wounds  of 
the  internal  jugular,  the  superior  vena  cava,  the  innominate,  the  subclavian 
and  the  axillary  veins.  The  wide-open  mouths  of  these  vessels  and  the  blood- 
stream flowing  toward  the  heart  favor  the  entrance  of  air  through  a  wound  in 
the  vein,  when  an  inspiration  occurs.     A  peculiar  gurgling  or  hissing  sound 


344  OPERATIONS    ON    INDIVIDUAL    STRUCTURES 

is  heard  as  the  air  rushes  in.  The  symptoms  wiU  depend  on  the  amount  of  air 
which  enters.  If  small  in  quantity,  no  harm  beyond  labored  breathing  and 
rapid  heart  action  may  result.  If  a  large  quantity  enters,  death  may  occur  at 
once,  the  air  collecting  in  the  right  side  of  the  heart  and  preventing  the  con- 
traction of  the  right  ventricle.  The  accident  occurs  more  frequently  in  surgical 
operations  than  under  other  circumstances.  The  treatment  consists  in  instant 
compression  on  the  cardiac  side  of  the  injured  vein  and  the  flooding  of  the  field 
of  operation  with  sterile  water  until  the  vessel  is  secured.  Inhalations  of 
oxygen  should  be  given,  compression  should  be  made  on  the  chest  wall  to  favor 
forced  expiratory  movements,  electricity  should  be  applied  over  the  heart,  and 
the  limbs  should  be  bandaged. 

In  operations  about  the  lower  and  anterior  part  of  the  neck  a  competent 
assistant  should  stand  ready  to  make  compression  between  the  point  where  a 
large  vein  is  endangered  and  the  heart,  in  order  that  aspiration  of  air  may  be 
avoided  in  case  the  vein  is  wounded.  When  large  venous  channels  are  discov- 
ered to  be  involved  in  the  neoplasm  during  its  removal,  these  should  be  divided 
between  two  ligatures  preliminarily  applied. 

Lateral  Ligation  of  Veins.— Small  lateral  injuries  of  veins,  or  an 
injury  of  a  small  vein  at  the  point  where  it  joins  a  main  channel,  may  require 
the  application  of  a  lateral  ligature.  Under  aseptic  conditions  small  wounds 
of  the  largest  vein  may  be  dealt  with  in  this  manner.  Under  these  circum- 
stances the  repair  takes  place  without  thrombus  and  the  lumen  of  the  vein 
remains  patent.  The  wound  in  the  wall  of  the  vein  is  grasped  with  a  hemo- 
static forceps  and  tied.  Large  wounds  of  the  veins,  in  cases  in  which  it  is 
undesirable  to  ligate  the  latter,  are  best  dealt  with  by  suturing.  In  the  case 
of  a  deep  and  inaccessible  vein  the  hemostatic  forceps  may  be  permitted  to 
remain  in  situ  for  several  days  (forcipressure). 

Suture  of  Veins.— This  operation  is  particularly  indicated  in  Avounds 
of  large  veins.  The  wounded  portion  of  the  vein  is  isolated  by  temporarily 
constricting  it  on  each  side.  Sutures  of  silk  or  fine  chromicized  catgut  are 
employed.  If  the  latter  material  is  used  a  second  row  of  perivascular  sutures  is 
applied  (Senn).  Approximation  of  the  intima  is  not  essential  to  success 
(S  c  h  e  d  e).  Silk  sutures,  when  used,  are  always  cast  off  in  a  direction  away 
from  the  lumen  of  the  vessel.  The  dangers  of  thrombus  formation  from  this 
cause  are  therefore  but  slight. 

Complete  transverse  separation  of  large  veins  requires  that  both  ends  be 
ligated. 

LIGATION  OF  ARTERIES  IN  CONTINUITY 

Indications.— The  indications  for  ligation  in  continuity  are  (1)  those 
arising  from  injury;  (2)  those  arising  from  inflammatory  processes;  (3)  those 
arising  from  tumor  formations.  In  all  procedures  except  that  of  B  r  a  s  d  o  r  , 
the  ligature  is  applied  between  the  heart  and  the  point  of  injury  or  disease,  the 
blood-supply  of  the  part  being  thus  restricted.  Complete  arrest  of  blood-supply 
is  prevented  by  the  collateral  circulation. 

In  case  of  injury  (punctured  wounds,  gunshot  wounds,  and  contusion  of 
arteries)  the  ligature  is  to  be  placed  as  near  as  possible  to  the  point  of  injury, 
and  above  and  below  the  latter.  If  necessary,  the  wound  of  the  soft  parts  is  to  be 
enlarged  to  accomplish  this,  but  when  this  can  be  accomplished  only  with  great. 


OPKRATIUXS    OX    BLOOD-VESSELS 


345 


difficulty  and  the  case  is  urgent,  ligation  at  a  distance  from  the  bleeding  point 
is  indicated.  In  localities  in  which  the  collateral  circulation  is  rapidly  estab- 
lished, ligation  in  coiuiiniity  may  be  followed  l)y  ligation  at  the  point  of  injury. 

Arterial  secondary  hemorrhage  furnishes  an  indication  for  ligation  in 
continuilN'.  Secondar}-  hemorrhage  rarely  occurs  under  aseptic  conditions. 
It  is  generally  due  to  either  contusion  of  the  arterial  coats,  these  subsequently 
giving  wav,  or  septic  inflammatory  changes  in  the  vessel  or  surrounding  ])arts, 
or  both.  It  is  also  known  as  "septic  after-hemorrhage."  It  is  to  be  dis- 
tinguished from  recurring  hemorrhage  which  occurs  within  five  or  six  hours 
after  the  injury,  instead  of  as  many  days.  In  recurring  hemorrhage  the  wound 
is  to  be  reopened  and  the  source  of  the  bleeding  sought.  In  septic  after-hem- 
orrhage, however,  the  condition  of  the  tissues  at  the  site  of  the  original  wound 
is  such  as  to  preclude,  as  a  rule,  a  search  for  the  bleeding  point.  The  vessel 
must  be  ligated  at  a  distance.  Ligation  in  con- 
tinuity is  also  indicated  in  certain  cases  of  trau- 
matic aneurism  {ride  infra). 

Prophylactic  ligation  in  continuity  is  in- 
dicated where  an  operative  procedure  is  about 
to  be  instituted,  in  which  it  is  more  than  likely 
that  the  arterial  trunk  must  be  divided.  This 
may  likewise  be  employed  to  prevent  great  loss 
of  l3lood  during  the  operation  (extirpation  of 
tongue,  resection  of  the  superior  maxillary  bone, 
etc.).  Exposure  of  the  vessel,  and  the  placing 
of  a  ligature  in  position  ready  to  be  tightened 
in  case  of  emergency,  may  also  be  practised. 

Provisional  arrest  of  the  blood-supply  of 
parts  involved  in  proposed  operations  by  tem- 
porary occlusion  of  the  main  tiimk  is  of  value 
at  times.  The  best  instnmient  for  this  pur- 
pose, the  jaws  of  which  should  be  guarded  by 
niliber,  is  that  de^lsed  by  C  r  i  1  e  ,  of  Cleveland 
(Fig.  130).  In  the  absence  of  this,  a  traction  loop  or  a  piece  of  tape  passed 
about  the  vessel  with  the  ends  carefully  twisted  and  clamped  may  be  used. 
Even  the  slightest  injury  to  the  vessel  must  be  avoided  lest  coagulation  of  the 
blood  take  place,  the  resulting  clot  being  subsequently  displaced  and  produc- 
ing serious  disturbances,  particularly  in  the  case  of  the  carotid  arteries. 
From  the  theoretic  standpoint,  and  in  the  absence  of  sufficient  operative 
experience  to  confirm  the  experimental  observations  made,  the  propriety 
of  applying  the  method  in  the  last-named  situation  is  questionable. 

Ligation  in  Continuity  for  Aneurism.— This  is  indicated  by  func- 
tional disturbances  due  to  the  presence  of  the  tumor,  growth  of  the  latter  with 
attenuation  of  its  walls,  and  threatened  spontaneous  rupture  and  consequent 
fatal  hemorrhage. 

Ligation  of  the  trunk  above  and  below  the  sac  and  extirpation  of  the  latter, 
the  old  operation  of  An  t  y  1 1  u  s,  is  the  simplest  method  of  treating  aneurism. 
^Yhen  the  aneurism  occupies  the  greater  portion  of  the  artery,  the  method  is  not 
applicable.  Even  after  successful  ligation  above  and  below  the  aneurism 
difficulties  mav  be- met  with  in  extirpation  of  the  sac.     Under  these  circum- 


Crile's  Clamp  ;  2, 
Rubber  Tubixg  for  Slipping 
OVER  THE  Ends  of  the 
Clamps;  3,  Clamp  Applied  to 
Artery. 


346 


OPERATIONS    ON   INDIVIDUAL   STRUCTURES 


stances  large  branches  may  exist  in  the  sac  and  fatal  hemorrhage  follow  the 
attempt  to  remove  the  latter. 

Ligation  in  continuity  between  the  aneurism  and  the  heart,  the  opera- 
tion of  Hunter,  is  the  best  known  and  most  commonly  practised  of  the 
operations  for  the  cure  of  this  disease.  The  retardation  of  the  flow  of  blood  in 
the  sac  leads  to  coagulation,  and  obliteration  of  the  sac  follows.  This  opera- 
tion is  successful  in  a  certain  proportion  of  cases.  If  the  collateral  circulation 
is  established  before  obliteration  of  the  aneurismal  sac  occurs,  pulsation 
returns  after  some  days.  On  the  other  hand,  sudden  interruption  of  the  l)lood- 
current,  particularly  in  elderly  persons  with  endarteritis  (see  page  93),  may 
lead  to  gangrene  of  the  extremity. 

Peripheral  Ligation. — Where  the  central  portion  of  the  artery  is  not  accessi- 
ble and  Hunter's  operation  cannot  be  performed,  peripheral  ligation  may 


Fig.   131. — Matas's  Operation  for  the  Cure  of  Axeurism. 

A,  Showing  the  process  of  obliteration  of  the  orifices  of  the  aneurismal  sac  in  a  sacculated  aneurism ;   B, 

the  obliteration  of  the  orifice  completed. 


be  resorted  to  (Bras  dor).  It  is  used  almost  exclusively  for  the  cure  of 
aneurism  of  the  innominate  artery.  The  ligature  is  applied  to  either  the  right 
common  carotid  or  the  subclavian.  As  no  branches  are  given  off  from  this 
point  of  the  aneurism,  the  formation  of  a  thrombus  advancing  from  the  site  of 
ligation  will  lead  to  obliteration  of  the  sac. 

Incision  of  the  sac  and  subsequent  ligation  constitute  a  very  bold  pro- 
cedure. The  index-finger  seeks  the  point  of  ingress  of  the  blood  and  is  made 
to  act  as  a  plug  to  the  vessel,  being  withdrawn  only  at  the  moment  of  drawing  a 
ligature  taut  about  the  artery.  It  is  rarely  indicated  except  in  those  cases  of 
aneurism  of  the  external  iliac  in  which  the  tumor  reaches  to  the  common  iliac 
and  precludes  the  use  of  the  operation  of  H  u  n  t  e  r  .  It  is  too  dangerous  for 
general  application. 

Matas's  Method  of  Arteriorrhaphy  for  the  Radical  Cure  of  Aneurism. 
— In  this  operation  the  sac  is  obliterated  by  a  plastic  procedure  and  the  com- 


OPERATIONS    OX    BLOOD-VESSELS 


347 


niunication  hetwetni  it  and  the  artery  closed,  while  at  the  same  time  an  attempt 
is  niaile  to  preserve  the  lunu^n  of  the  artery. 

'Hie  stei)s  of  the  operation  include  (1 )  prophylactic  hemostasia,  which  may  be 
accomplished  by  means  of  a  C  r  i  1  e  '  s  clamp  or  a  silk  traction  loop,  applied, 
when  necessary,  to  the  distal  as  well  as  to  the  proximal  pole  of  the  aneurism,  as, 
for  instance,  in  aneurisms  in  the  cervical  region ;  (2)  exposure  of  the  sac  by  a  free 
incision  parallel  to  the  long  axis  of  the  tumor;  (3)  opening  of  the  sac  and  evacua- 
tion of  its  contents;  (4)  closure  of  the  arterial  orifice  or  orifices  by  means  of 
sutures  so  placed  as  to  effect  broad  apjjroximation  of  the  serous  surfaces  of  the 
margins  of  the  openings;  (5)  removal  of  the  clamp  or  constricting  loop  and  test 
of  the  sutures;  (6)  obliteration  of  the  aneurismal  sac. 

In  the  case  of  a  sacculated  aneurism  the  operation  is  comparatively  simple. 
The  orifice  of  communication  between  the  artery  and  the  sac  is  closed  either  by 
interrupted  sutures  or  by  a  continuous  suture  of  chromicized  catgut  (Fig.  131). 


Fig.   132. — Matas's  Operation  for  the  Cure  of  Aneurism. 
A,  Showing  the  method  of  closing  the  orifices  and  constructing  a  new  arterial  channel  in  a  fusiform  aneu- 
rism ;  B,  removal  of  the  guide. 


In  fusiform  aneurisms  the  procedure  is  somewhat  more  complicated.  Here 
two  large  openings  are  present,  the  space  between  them  representing  the 
continuation  of  the  floor  of  the  parent  artery.  This  space  must  be  preserved, 
if  possible,  in  order  to  aid  in  the  construction  of  a  new  arterial  channel.  This 
is  effected,  where  the  flexible  character  of  the  sac  will  permit,  by  lifting  two 
lateral  folds  of  the  sac  and  bringing  them  together  by  suture  over  a  soft  rubber 
guide,  in  the  same  manner  as  that  adopted  in  W  i  t  z  e  1 '  s  method  of  gas- 
trostomy. The  sutures  are  all  placed  while  the  guide  (a  soft  rubber  catheter  of 
proper  size)  is  in  position  (Fig.  132,  A).  The  sutures  are  all  tied  with  the 
exception  of  the  two  middle  ones.  These  are  drawn  to  one  side  and  the  catheter 
withdrawn  (Fig.  132,  B).  The  remaining  sutures  are  now  tied.  "Where  the 
condition  of  the  vessel  walls  will  not  permit  the  lifting  of  these  to  form 
lateral  folds  for  suturing  over  a  guide,  as  is  not  infrecjuently  the  case  in  aneu- 


348 


OPERATIOXS    OX    INDIVIDUAL    STRUCTURES 


risms  of  pathologic  origin,  the  orifices  are  closed  by  one  or  more  tiers  of  sutures 
extending  along  the  space  representing  the  floor  of  the  parent  vessel  and  includ- 
ing both  openings  (Fig.  133). 

After  all  of  these  procedures  obliteration  of  the  remaining  portion  of  the 
cavity  of  the  aneurismal  sac  is  effected  by  approximating  its  walls  by  succes- 
sive layers  of  sutures.  The  skin  edges  are  then  sutured  and  the  dressings 
applieci  in  such  a  manner  as  to  fill  the  hollow  on  the  surface  left  by  the  oblitera- 
tion of  the  aneurismal  sac. 

In  the  after-treatment  of  all  cases  of  obliteration  of  the  main  vessel  of  supply 
of  an  extremity  the  latter  should  be  kept  elevated  to  favor  the  return  circulation 
and  the  temperature  maintained  by  loosely  bandaging  with  cotton  batting  and 
bv  applying  artificial  heat. 

Other  Methods  of  Treating  Aneurism.— Digital  and  instrumen- 
tal compression  may  be  applied  whenever  the  position  of  the  aneurism  permits 

the  application.  These  methods  are  de- 
void of  danger  but  excessively  painful. 
To  be  effective  the  compression  must  be 
kept  up  for  several  days.  Disappear- 
ance of  pulsation  and  induration  of  the 
sac  are  the  indications  for  its  cessation. 
In  case  of  digital  compression  relays  of 
assistants  are  necessary.  In  instrumental 
compression  the  point  of  pressure  must 
be  occasionally  changed.  These  are  lim- 
ited in  their  application,  but  in  individual 
cases  have  given  favorable  results,  par- 
ticularly in  the  lower  extremities.  Few 
patients,  however,  have  sufficient  forti- 
tude to  endure  the  pain  of  their  appli- 
cation. To  assist  this,  hypodermic  injec- 
tions of  morphin  may  be  given. 

Chemical  means  calculated  to  bring 
about  coagulation  of  the  blood  have  been 
recommended.     These,  as,  for    instance, 
the  injection  of  the  solution  of  the  ses- 
quichlorid  of  iron  into  -the  sac,  cannot  be  too  strongly  condemned. 

Galvanopuncture  consisting  of  the  introduction  of  two  fine  needles  as 
electrodes  into  the  sac,  and  the  coagulation  of  the  blood  by  the  passage  of  the 
galvanic  current,  as  well  as  acupuncture,  or  the  introduction  of  several  needles 
into  the  sac,  the  needles  remaining  there  for  several  hours  in  order  to  favor 
coagulation,  has  not  been  sufficiently  long  on  trial  to  determine  its  advantages 
or  dangers. 

The  introduction  of  foreign  bodies  into  the  cavity  of  the  aneurism  in 
order  that  the  blood  may  coagulate  around  them  has  been  recommended.  For 
this  purpose  horsehair,  catgut,  and  fine  silver  steel  and  copper  wire  have  been 
employed.  A  number  of  yards  of  the  material  is  introduced  through  a  cannula 
(Moore).  The  wire  after  insertion  may  be  connected  with  the  anode  of  a 
galvanic  battery  (Corradi).  There  are  two  dangers  to  be  apprehended 
from  this  procedure:    (1)  fatal  hemorrhage  may  result  from  the  puncture  by 


Fig.   133. — Matas's    Operation   for    the 

Cure  of  Aneurism. 

Showing  the  orifices  in  the  aneurismal  sac  in 

process  of  obliteration  by  suturing. 


OPERATIONS    ON    BT.OOD-YICRSKLS  349 

the  cannula;  (2)  at  the  very  bcfiinniiii^  of  the  o])eration  small  clots  may  be 
swept  away,  and,  in  the  shape  of  emboli,  jiroduce  disturbances  at  a  distance. 
Nevertheless  the  method  is  worthy  of  trial  in  inoperable  cases. 

The  method  of  "  needling"  (]\I  a  c  e  w  e  n)  aims  at  the  formation  of  a  white 
thrombus  on  the  innc>r  surface  of  the  sac.  Long  steel  needles  are  introduced  and 
gently  manipulated  so  as  to  produce  irritation  of  the  entire  lining.  Several 
needles  may  be  used  at  each  sitting  and  the  operation  may  be  repeated  until  the 
thickening  of  the  walls  of  the  sac  is  evident. 

Injections  of  ergot  in  cases  of  aneurism  in  the  manner  recommended  in 
varices  has  l)cen  suggested  (L  a  n  g  e  n  b  e  c  k).  The  acjueous  solution  is 
injected  by  means  of  a  hypodermic  syringe  around  the  outside  of  the  wall  of  the 
sac.  The  ergot  produces  contraction  of  the  muscular  apparatus  of  the  vessel. 
The  method  is  applicable  only  in  the  earliest  stage  of  the  disease ;  as  the  latter 
progresses,  the  muscular  fibers  disappear. 

Ligation  in  continuity  in  the  treatment  of  neoplasms  has  not  been 
very  successful.  In  the  case  of  the  external  carotid  the  addition  of  excision  of 
the  branches  of  the  vessel  on  both  sides  (Dawbarn)  promises  to  become  a 
valuable  resource  in  the  treatment  of  malignant  disease  occuri'ing  in  the  area  of 
supply  of  this  vessel.  The  lingual  arteries  have  been  tied  in  carcinoma  of  the 
tongue  (D  u  m  a  r  q  u  a  y). 

Ligation  of  the  femoral  artery  has  been  employed  in  elephantiasis 
arabum  (Carnochan).  Hueter's  suggestion  of  ligature  of  the  exter- 
nal iliac  in  the  same  class  of  cases  has  likewise  been  followed.  The  rationale 
of  the  method  is  not  clear.  In  a  young  man  in  whom  I  ligatecl  the  external 
iliac  for  elephantiasis  arabum  affecting  but  one  extremity  the  method  proved 
successful.     After  twelve  years  the  patient  still  remains  free  from  the  disease. 

Methods  and  General  Technic  of  Ligation  in  Continuity. — The  selection 
of  the  proper  site  for  placing  the  ligature  was  formerly  considered  of  the  greatest 
importance.  It  was  deemed  necessary,  in  order  to  secure  a  long  coagulum,  to 
place  the  ligature  as  far  as  possible  from  a  branch  of  the  vessel  as  was  consistent 
with  the  purpose  for  which  the  ligature  was  employed.  The  occurrence  of  suppu- 
ration, almost  a  necessary  sequence  of  the  operation  and  an  accompaniment  of 
the  process  of  separation  of  the  ligature  in  preaseptic  days,  in  the  case  of  a 
short  coagulum  was  not  infrequently  followed  by  secondary  hemorrhage  and  the 
necessity  for  a  repetition  of  the  ligation.  These  precautions  are  superfluous 
when  the  aseptic  ligature  and  aseptic  wound  treatment  are  employed.  lender 
these  circumstances  the  size  of  the  thrombus  is  of  but  little  importance. 

In  addition  to  the  requisite  anatomic  knowledge,  it  will  be  found  useful  to 
identify  the  vessel  by  its  pulsation  whenever  possible.  It  is  likewise  necessary 
before  applying  the  ligature  to  make  digital  compression  at  the  point  at  which 
the  occlusion  is  intended  to  be  made.  If  pulsation  ceases  in  the  area  intended 
to  be  deprived  of  supply,  the  operation  is  to  be  proceeded  with;  other^dse  not. 

In  making  the  necessary  incision  for  ligation  of  the  vessel,  care  must  be 
taken  not  to  draw  the  skin  away  from  the  line  of  the  vessel  to  one  or  the  other 
side.  The  incision,  as  a  rule,  is  made  parallel  to  the  long  axis  of  the  vessel, 
though  there  are  several  exceptions  to  this  rule  (see  Regional  Surgery).  The 
skin,  subcutaneous  connective  tissue,  and  fascia  are  separated  by  the  incision, 
the  different  structures  being  steadied  by  the  anatomic  forceps.  In  making 
the  dissection,  the  muscular  structures  should  be  spared  as  much  as  possible. 


350 


OPEEATIOXS    OX    IXDIVIDUAL    STRUCTURES 


In  reaching  the  sheath  the  exact  location  of  the  vessel  is  ascertained  by 
feeling  for  its  pulsation  with  the  point  of  the  finger.  In  case  pulsation  is  absent 
the  artery  is  identified  as  a  flat  cord  with  a  solid  feel;  the  vein  which  accom- 
panies it  appears  soft,  while  the  nerve  has  a  more  solid  but  roundish  feel.  The 
relation  which  these  bear  to  each  other  must  also  be  borne  in  mind.  In  order 
to  avoid  injury  to  the  vessel  in  opening  the  sheath  the  latter  is  grasped  by  the 
anatomic  forceps,  lifted  away  from  the  vessel,  and  opened  by  an  incision  parallel 
to  the  arterial  wall. 

The  sheath  is  now  separated  from  the  vessel  by  means  of  the  blunt  end  of 
the  scalpel  or  a  probe,  each  edge  of  the  incision  being  steadied  in  turn  by  the 
anatomic  forceps  for  that  purpose.     This  being  accomplished  a  blunt  aneurism 

needle  (Fig.  134)  armed  with  a 
double  ligature  is  passed  around  the 
vessel.  A  bent  probe  with  an  eye 
may  be  made  to  answer  the  purpose. 
The  instrument  should  always  be 
passed  from  the  direction  of  the  vein, 
in  order  to  avoid  injury  to  the  latter. 
The  arterial  wall  must  not  be  grasped 
by  the  forceps,   else  injury  to  this 

1^  >^  may  result.     It  is  well  to  ligate  at 

IH  ^H  two  points  and    divide    the   artery 

^H  ^H  between  these;  the  gaping  lumen  of 

^H  ^H  the  vessel  will  positively  identify  it. 

^H  ^H  In    tying  the   ligature  it  is  not 

^H  ^H  always  necessary  to  apply  a  surgi- 

^H  ^H  cal   knot.     The   ordinary  flat  knot 

^H  ^H  will  answ^er.     The  turns  of  the  knot 

^m  ^M  are  directed  to  the  arterial  wall  by 

^m  ^M  the  tips  of  the  index-fingers.      The 

^M  ^m  first  turn  is  to  be  drawn  moderately 

^1  ^M  tight;   it   is   not  necessary  that  the 

^H  ^H  operator  should  feel  the  giving  way 

^^  ^^  of  the  middle  and  inner  coats  of  the 

vessel,  as  was  formerly  taught.     The 
second   turn  should    be  only    suffi- 
ciently  drawn    to   secure   the   first 
turn  against  slipping.     A  third  turn  affords  additional  security. 

For  the  larger  vessels  sterilized  silk  is  preferred  to  catgut  by  some  surgeons, 
through  fear  of  a  too  early  loosening  of  the  latter.  Catgut  boiled  in  alcohol 
(page  53)  will  last  sufficiently  long  for  any  vessel. 

The  ends  of  the  ligature  are  cut  off  about  one-eighth  of  an  inch  from  the 
knot.     The  wound  is  sutured  in  its  entire  length  and  dressed  aseptically. 

OPERATIONS  ON  VEINS 

Lateral  ligation  of  veins  has  been  already  described.  Transverse  ligation  in 
continuity  of  large  veins  is  somewhat  more  difficult  than  in  the  case  of  arteries. 
With  care,  however,  it  may  be  accomplished.  Smaller  veins  may  be  ligated  as 
readily  as  arteries. 


Fig.   134. — Aneurism  Needles. 
a,  Straight;    6,  left;    c,  right. 


OPEEATIOXS    ON    BLOOD-VESSELS  ■'ol 


Ligation  in  continuity  of  vein,  i,  sometimes  mdioated  and  practised 
in  c^  e-<  of  varices.  Ligation  of  tlie  internal  saplienous  vem  (  f  r  e  n  d  e  1  e  n  - 
bur")  just  below  the  point  where  the  superficial  circumflex  >hac,  the  su,>erfici  1 
eri-aic  and  the  superficial  pudic  veins  join  the  vessel  near  the  saphenous 
oSn"  and  ligation  of  the  external  saphenous  itt  the  middle  hne  of  the  pos- 
terior a°pect  of  the  left  leg  just  before  this  vessel  pierces  the  deep  asc.a  to  join 
he  poplfteal  vein,  are  employed  for  the  cure  of  varicose  yems  of  the  thigh  and 
lel  When  the  superficial  epigastric  and  superficial  pudic  vems  are  mvolved 
tiresp  ve«el=  should  l>e  ligated  separately.  . 

\lultiple  Ligation.-The  multiple  ligation  of  vems  commumcatmg 
with  V  ices  with  formal  excision  of  the  latter.  Ls  often  practised  wuh  adyan- 
a"e  Ivulsion  of  the  vein,  i.  c.  its  removal  by  traction  after  its  hgation 
throu^lf  two  small  openings  placed  some  cUstance  apart  is  sometmies  pra  ti- 
caMe  The  so-caUed  "  earter-operation"  consists  of  a  circular  mcis.on  of  the 
tab  whch  dhides  all  "the  superficial  strxictures,  inclucUng  the  vems.  which 
^er  are  hVated  at  both  di^ided  ends.  The  method,  if  emplo.ved  at  all.  should 
be  reserved^lnr  the  most  aggravated  and  mtractable  cases 

Venesection.-TMs  Uttle  operation,  formerly  so  frequent  y  emplojed, 
is  now  but  rarelv  called  for.  The  median  basiUc  vein  at  the  l,end  of  the  elbow 
usuall  chosen.  The  parts  should  be  prepared  in  an  aseptic  manner  and  a 
bandTg  appLl  sufficiently  tight  to  restrict  the  return  flow  of  blood,  but  it  must 
noUntertere  with  the  circulation  through  the  vessel,  as  shown  by  the  puke  at  the 
writ  The  supei-ficial  veins  become  filled.  The  escape  of  blood  b  favored  b 
vo  uman -rasping  movements  of  the  hand.  When  sufficien  blood  has  escaped, 
he  con5ri°  ting  bandage  is  removed  and  an  aseptic  gauze  bandage  apphed. 

Trans  Usion.-Blood  taken  from  the  circulation  of  one  mchvidual  and 
imroduced  too  that  of  another  in  case  of  excessive  hemorrhage  has  been  practi- 
callv  abandoned  m  favor  of  mtravenous  normal  saline  mfusion.  This  resrUt 
has  been  brought  about,  first,  beca.u»e  of  the  difficidty  of  obtammg  blood  in 
sufficien"  quanUtv:  secoM.  from  the  delay  mcident  to  the  operation  thircl,  on 
a  foimt  of  the  i-isks  from  thrombosis  and  emboUsm  when  the  direct  method  is 
em,Z4d.  and  the  fever  and  hematuria  when  the  mdirect  method  is  used. 

intravenous    Saline    Infusion.-Tlii,   operation  is  usually  performed 
either  Aroi"h  the  mecUan  basilic  or  the  mecUan  cephalic,  at  the  bend  of  the 
W.     A  constricting  bandage  is  placed  on  the  upper  part  oft^e  a™  to 
re  °ram  the  flow  of  btood  from  the  Umb.     The  vem  is  bared  and  cleared  for 
Iboutl  toch,  and  two  ligatures  passed,  one  above  the  pomt  of  mtenc  ed  open- 
tt  the  vein  and  one  below  (Fig.  13.5).     A  sUghtly  curbed  cannub  .s  now 
mroduced  throu^-h  a  small  valve-shaped  opemng  made  m  the  ^em  bj  a  smp 
wi^  !he  polmrd-scissors.  the  infusion  fltud  being  ahowed  to  Aow  while  th.^ 
bein..  done  in  order  to  gtiard  against  the  emrance  of  air.     The  upper  hgature 
t  now  ti^hteMd  around  the  caiSirUa  to  hold  the  latter  in  place^and  to  prevent 
LCeiweU  while  the  lower  Ugature  closes  the  vein  below.     The  oonstncting 
banda°'e  Ls  now  removed.     If  gra^-ity  is  employed  the  reser^w  contaming  the 
Musion  fluid  should  be  held  about  three  feet  above  the  patient's  chest.     Or 
tt'a^^amus  show^  in  figure  135  may  be  used.     A  0-6  per  cent^so  ution  of 
chloric!  of  sodium  should  be  employed  at  a  temperature  ""^^  m  cl  lorid  one 
S  z  u  m  a  n  n  '  s  transfusion  solution  consists  of  slx  parts  of  sodium  chlond.  one 
w  of  carbonate  of  soda,  and  one  thousand  parts  of  stenle  wa  er.     In  case  o 
emergencv  a  transfusion  fluid  can  be  rapidly  extemporized  by  dissohtnga  level 


352 


OPERATIONS    OX    IXDIVIDUAL    STRUCTURES 


teaspoonful  of  table  salt  in  a  pint  of  l:)oiled  water.  The  solution  should  be 
strained  or  filtered.  This  solution,  used  at  a  temperature  which  the  hand  will 
bear  without  discomfort,  will  answer  every  practical  purpose.  The  quantity 
will  vary  with  the  recjuirements  of  the  case;  from  two  and  one-half  to  three 
pints  is  the  usual  ciuantity.  Care  is  to  be  exercised  not  to  inject  too  much  in 
cases  in  which  secondary  hemorrhage  is  to  be  feared  (^I  i  k  u  1  i  c  z). 

Intravenous  infusion  is  employed  as  follows:  (1)  for  replacing  lost  fluids 
following  severe  hemorrhage;  (2)  for  the  restoration  of  heat  to  the  body  in 
surgical  shock  and  analogous  conditions;  (3)  for  the  removal  of  toxic  substances 
by  provoking  diuresis  in  cases  of  renal  insufficiency.  It  has  also  been  used  in 
illuminating-gas  poisoning  combined  with  venesection.  Under  these  circum- 
stances it  is  difficult  to  apportion  the  credit  for  the  favorable  outcome  in  success- 
ful cases.  The  contraindications 
to  intravenous  infusion  are  (1)  the 
presence  of  infective  emboli  liable  to 


A  B 

Fig.  13.5. — Intravenous  Saline  Infusion. 
A,  The  lower  ligature  is  tied  and  the  upper  ligature  is  in  place  ready  for  tying.  The  valve-shaped 
opening  in  the  vein  is  shown  ready  to  receive  the  cannula.  B,  Flask  containing  the  saline  solution. 
This  flask  is  an  ordinary  wash-bottle,  the  long  glass  tube  of  which  is  connected  to  the  infusion  cannula 
and  the  short  glass  tube  to  a  rubber  bulb  with  valves.  By  pumping  air  into  the  flask  above  the  solu- 
tion the  latter  is  forced  into  the  veins. 

be  forced  into  the  circulation  by  the  operation;  (2)  the  presence  of  advanced 
dropsy;  (3)  marked  cardiac  insufficiency;  (4)  cyanosis,   or  pulmonary  edema. 

The  most  frec^uent  employment  of  intravenous  infusion  in  surgical  practice 
is  in  combating  shock  accompanying  or  following  operations.  It  is  in  this  class 
of  cases  that  the  higher  temperatures  are  employed.  The  use  of  strychnin  may 
be  combined  with  that  of  the  saline  infusion  when  indicated.  The  strj^chnin  is 
introduced  along  with  the  saline  fluid  by  injection  from  a  hypodermic  syringe 
through  the  rubber  tube  of  the  apparatus.  This  should  be  done  very  slowly. 
Adrenalin  chlorid  in  1  :  1000  solution  may  be  employed  in  the  same  manner. 
From  10  to  15  minims  of  the  latter  may  be  thus  introduced  and  repeated  every 
few  minutes  while  the  infusion  is  progressing,  until  its  effects  in  increasing  the 
blood-pressure  are  manifested  (C  r  i  1  e). 

Subcutaneous  Infusion  or  Hypodermoclysis. — From  one  to  two 
pints  of  the  saline  fluid  may  be  introduced  l^eneath  the  skin  in  cases  in  which 


OPERATIONS    OX    BLOOD   VESSELS  353 

the  indications  for  infusion  are  less  urgent,  or  for  the  purpose  of  supplement- 
ing an  intravenous  infusion  when  this  has  been  given.  From  one  to  three 
pints  of  the  saline  infusion  may  also  l^e  given  hy  the  rectum  for  the  latter  pur- 
pose. By  these  means  the  necessity  for  a  second  intravenous  infusion  may 
sometimes  be  avoided.  For  subcutaneous  or  intracellular  infusion  any  large 
hollow  needle  will  answer.  This  and  a  clean  douche  bag,  an  ordinary  Ijulb 
syringe,  or  an  irrigator  to  which  the  necessary  rubl^er  tul^ing  can  be  attached 
constitute  the  requisite  apparatus.  The  infusion  is  made  beneath  the  breasts. 
Should  it  become  necessary  to  repeat  the  infusion,  the  interscapular  region  or 
the  inner  surface  of  the  thighs  should  be  selected. 

Autotransfusion  consists  in  the  temporary  displacement  of  the  l^lood 
in  the  direction  of  the  essential  vital  organs  in  cases  of  excessive  loss  of  blood 
in  wliieh  death  is  threatened  from  embarrassment  of  the  general  circulation. 
One  of  the  methods  of  effecting  the  displacement  of  the  blood  is  to  incline  the 
patient  at  an  angle  of  45  degrees  by  raismg  the  foot  of  the  bed.  By  this  means 
the  force  of  gravity  is  made  available  and  the  action  of  the  heart  operates  to 
force  the  blood  in  the  direction  of  least  resistance,  namely,  in  the  direction  of  the 
cardiac  and  respirator}'  centers.  Another  method  is  to  hold  the  limb  in  a  verti- 
cal position  until  it  is  practicall}'  deprived  of  its  blood,  when  a  constricting  band 
is  placed  at  its  base  to  prevent  the  blood  from  reentering  when  the  limb  is 
lowered.  A  still  more  etficient  method  is  to  bandage  the  limb  from  below 
upward,  its  blood  being  rapidly  forced  out  in  this  way.  A  limb  may  be  kept 
deprived  of  blood  in  this  manner  for  two  hours  with  safety ;  in  case  of  neces- 
sity, the  limbs  can  be  alternately  bandaged  or  constricted. 

Autotransfusion  is  of  great  value  as  a  temporary'  resource.  It  should  be 
employed  only  after  the  hemorrhage  is  arrested.  It  should  not  take  the  place 
of  intravenous  saline  infusion,  but  may  be  used  to  gain  time  to  make  the  latter 
available. 

General  Treatment  of  Hemorrhage. — Internal  medication  is  of  prac- 
tically no  value  in  the  arrest  of  hemorrhage.  Ergot,  of  so  much  value  in  post- 
partum hemorrhage  from  inertia  of  the  uterus,  is  of  no  use  in  surgical  hemor- 
rhage except  in  cases  of  capillar}'  oozing,  and  in  these,  except  in  the  cases  in 
which  the  bleeding  area  is  not  accessible,  the  method  of  tamponade  may  well 
replace  it.  It  may  be  advantageously  employed,  however,  in  combating  the 
shock  resulting  from  hemorrhage,  the  caliber  of  the  capillaries  being  dimin- 
ished by  its  action  as  a  vasomotor  constrictor,  and  the  heart  better  enabled 
to  control  the  general  circulation  (Livingstone).  Oil  of  turpentin  is 
employed  by  some  surgeons  in  five-drop  doses,  given  in  emulsion  and  repeated 
every  hah-hour.  Its  action  is  not  assured  and  it  is  liable  to  produce  strangury. 
Acetate  of  lead,  the  dilute  or  aromatic  sulfuric  acid,  and  similar  drugs  formerlv 
believed  to  increase  the  coagulability  of  the  blood,  are  no  longer   employed. 

Stimulation  is  to  be  avoided  as  long  as  bleeding  continues  or  is  likely  to 
recur.  Once,  however,  the  hemostasis  is  effective,  stimulation  is  to  be  pushed 
by  hot  diluted  alcoholic  drinks,  hot  enemas  of  saline  solution  and  whisky,  and 
the  hypodermic  use  of  digitalis  and  strychnin  for  the  purpose  of  bringing  about 
reaction  and  combating  excessive  prostration.  At  the  same  time  the  heat  of 
the  body  is  to  be  restored  by  hot-water  bottles  applied  to  the  extremities,  and, 
if  necessary,  to  the  tnmk  as  well.  A  hot-water  bottle  applied  to  the  precordia 
sometimes  answers  a  good  purpose.  In  carrying  out  these  measures  care  should 
be  taken  not  to  burn  the  patient. 
24 


354 


OPERATIONS    OX    INDIVIDUAL    STRUCTURES 


OPERATIONS   ON   NERVES 

Suture  of  Nerves. — This  is  required  in  complete  accidental  division  of 
nerve-trunks.  This  injury  occurs  at  points  where  nerve-trunks  are  super- 
ficially situated,  such  as  the  median  nerve  above  the  wrist  or  the  ulnar  nerve 
in  elbow- joint  resection.  Contusion  of  a  nerve  may  recjuire  removal  of  the  con- 
tused portion  and  the  suturing  of  the  nerve-ends. 

In  the  earher  attempts  to  suture  nerves  the  method  employed  was  that  of 
transfixion  of  the  entire  nerve  with  interrupted  sutures.  The  employment  of  a 
nonabsorbable  suture  led  to  frequent  and  mischievous  suppurative  inflam- 
mation. The  use  of  catgut  or  other  absorlDable  suture  material,  and  improve- 
ment in  the  technic  consisting  of  the  suture  of  the  neurilemma  of  the  divided 
ends  rather  than  the  entire  thickness  of  the  nerve-trunk  (W  e  b  e  r),  together 
with  H  u  e  t  e  r's  further  modification  of  perineural  suture  (Fig.  136,  suture  of 
the  connective  tissue  of  each  end),  marked  a  very  decided  advance  in  the  surger}^ 
of  the  nerves.  Accurate  approximation  and  healing  without  suppuration 
assure  excellent  results,  in  a  large  proportion  of  cases  (about 
67  per  cent,   P.   Bruns,    1884). 

Secondary  Nerve-suture. — In  cases  in  which  nerve- trunks 
have  been  divided  and  the  stumps  buried  in  a  mass 
of  cicatricial  tissue  with  loss  of  function,  these  may  be 
dissected  from  their  cicatricial  surroundings  and  sutured. 
If  the  nerve-ends  are  readily  approximated,  H  u  e  t  e  r  '  s 
suture  or  Weber's  neurilemma  suture  may  be  applied. 
If  there  is  considerable  tension  on  the  nerve-tnmk  in  re- 
placing it,  it  will  be  necessary  to  apply  the  transfixion  suture 
of  the  entire  thickness  of  the  nerve-trunk. 

The    results    of    secondary    suture    are  very  encouraging 
(24  successful  cases  out  of  33,  P.  Bruns).     One  case  was 
operated  on  nine  years  after  the  original  injury,  with  a  sue- 
Though  there  are  reports  of  extraordinarily 
rapid  restoration   of    function,    this   varies,  as  a  rule,  from 
three  months  to  two  years. 

Neuroplastic  Operations.— In  cases  of  marked  retraction  of  the  nerve 
stumps  or  loss  of  substance  preventing  ready  approximation  of  the  same, 
Letievant  (1872)  proposed  to  turn  down  a  flap  attached  by  a  pedicle 
from  one  nerve  stump,  and  to  attach  this  to  the  other.  The  most  brilliant 
success  in  the  employment  of  this  procedure  was  achieved  by  T  i  1 1  m  a  n  n  s  , 
in  a  case  of  division  of  the  ulnar  and  median  nerves (1882).  Another  ingenious 
operation,  also  introduced  by  L  e  t  i  e  v  a  n.t  ,  consists  in  suturing  the  central 
end  of  one  nerve-tnmk  to  the  peripheral  end  of  an  adjacent  nerve,  when  two 
neighboring  nerves  are  injured. 

In  cicatricial  union  of  ner\^es,  without  restoration  of  function,  a  longitu- 
dinal incision  is  made  through  the  middle  of  the  mass  of  scar  tissue,  extending 
well  into  the  healthv  nerA-e  substance  (Fig.  137,  A).  This  is  then  converted 
into  a  transverse  line  and  secured  by  suture  (Fig.  137,  B).  In  this  manner, 
ner\'e-tissue  is  brought  in  contact  with  nerve-tissue  (Bruns,  1893). 

In  cases  of  nonunion  with  bulbous  central  end,  in  order  that  a  large 
amount  of  the  length  of  the  nerve  may  not  be  sacrificed  in  getting  rid  of  the 


f1 

■ 


Fig.  136.— Perineu-  cessful    result. 
EAL  Suture. 


OPERATIONS    ON    NERVES 


355 


- 

Fig.    137. — Bruns's  Method  of  Nerve-suture. 

A,  Longitudinal  incision  through  cicatrix  extending 
into  normal  nerve;  B,  incision  shown  in  A,  united  trans- 
versely. 


latter,  tliis  is  s])lit  well  beyond  the  bulbous  extremity,  and  the  distal  end 
trimnietl  to  a  wedge  shape.  The  latter  is  then  sutured  into  the  split  of  the 
central  end,  as  shown  in  Fig.  13(S  (li  run  s). 

In  order  to  i)reA-ont  tlio  sutured  ])()rtion  from  being  compressed  by  the 
newly  formed  connective  tis- 
sue, it  has  been  proposed  to 
slip  a  decalcified  bone  tube  over 
the  nerve  before  suturing;  or 
the  tube  may  be  split  and  passed 
arountl  the  nerve  after  suturing. 
Strangulation  of  a  nerve 
from  its  embedment  in  a  mass 
of  cicatricial  tissue  or  callus 
sometimes  leads  to  impairment 
of  function,  without  coincident 
injury  to  the  nerve  itself.  The 
nerve  should  be  liberated  and 
enveloped  in  a  T  h  i  e  r  s  c  h 
skin-graft  (G 1  e  i  s  s)  to  prevent 
repetition  of  the  accident. 

After  all  operations  of  nerve- 
suturing  the  position  of  the 
parts  should  be  carefully  attended  to.  The  limb  should  be  placed  so  as  to 
bring  as  little  tension  as  possible  on  the  sutured  nerve.  As  soon  as  healing  has 
taken  place  electricit}'  and  massage  are  useful  adjuncts  to  treatment. 

Transplantation  of  Nerves.— G  luck  in  1880,  after  P  h  i  1  i  p  a  u  x 
and  V  u  1  p  i  a  n  '  s  experiments  (1870)  in  trans- 
plantation of  nerves  in  dogs,  attempted  to  place 
the  operation  on  a  surgical  basis  and  made  some  ex- 
periments for  that  purpose.  This  implantation  of 
completely  separated  portions  of  nerves  has  never 
been  successful  in  man,  though  it  has  been  perfectly 
accomplished  in  some  of  the  lower  animals. 

Neurotomy  and  Neurectomy. — Intractable 
neuralgia  sometimes  assumes  such  importance  as  to 
demand  division  of  the  nerve  for  its  relief. 
Otherwise  inoperable  but  excessively  painful  tumors 
also  require  division  of  the  sensory  nerve  supply- 
ing the  organ  involved,  e.  g.,  division  of  the  lingual 
nerve  in  inoperable  carcinoma  of  the  tongue.  For- 
merly motor  nerves  were  occasionally  divided  in 
cases  of  intractable  painful  convulsive  movements  in 
the  region  supplied,  e.  g.,  division  of  the  facial  for  tic  douloureux.  The  opera- 
tion of  nerve-stretching  has  now  quite  superseded  nerve-section  in  these  cases. 
Simple  division,  or  neurotomy,  is  found  to  be  quite  insufficient  to  meet  the 
requirements  of  permanent  interruption  of  function  in  sensory  nerves.  For 
this  reason  the  operation  of  neurectomy  has  taken  the  place  of  that  of  neu- 
rotomy. Without  this,  the  violent  pains  which  originally  demanded  the  oi3era- 
tion  soon  return.    The  object  of  neurectomy  is  to  excise  a  portion  of  the  nerve, 


Fig.  13S. — Nerve  Stump  United 
BY  Wedge  Method. 


356  OPERATIONS    ON    INDIVIDUAL    STRUCTURES 

in  order  to  prevent  reunion  of  the  cliA'ided  ends.  Idie  removal  of  at  least  two 
inches  has  been  shown  by  experiment  to  be  necessary  in  order  to  insure  against 
reunion.  These  operations  are  usually  performed  for  intractable  trigeminal 
neuralgia;  it  is  manifestly  impossible  to  remove  two  inches  from  any  of  the 
branches  of  the  fifth  pair.  All  that  can  be  done,  under  these  circumstances,  is 
to  remove  all  of  the  nerve  accessible ;  this  will  usually  include  the  trunk  to  the 
extent  to  which  it  passes  through  the  bony  canal,  from  its  exit  from  the  skull 
to  its  peripheral  distribution.  More  recently  the  cavity  of  the  skull  has  been 
invaded  (see  Intracranial  Neurectomy,  page  541). 

Crushing  of  the  Divided  Central  End  of  the  Nerve.— This  has  been 
suggested  to  prevent  a  return  of  the  neuralgia  by  arresting  nerve  regeneration. 
There  is  danger  of  inflammation  progressing  in  the  direction  of  the  brain  or 
spinal  cord  (ascending  neuritis)  occurring  as  a  result  of  this  procedure. 
Quite  as  effectual  and  far  safer  is  the  application  of  the  thermocautery  to  the 
central  end  of  the  divided  nerve. 

Relapses  of  intractable  neuralgia  following  neurectomy  are  not  always  due  to 
reunion  of  the  divided  nerve-ends.  The  development  of  a  neuroma  on  the 
central  end,  or  the  unfavorable  influence  of  the  cicatrix,  in  a  certain  proportion 
of  cases,  will  account  for  the  recurrence.  Further,  some  of  these  cases  have  a 
central  origin,  the  paroxysms  depending  on  some  peripheral  irritation  which  is 
conducted  along  the  intact  nerve.  The  latter  being  divided,  the  paroxysms 
cease  for  a  time  only.  The  condition  of  these  sufferers  will  sometimes  demand 
repeated  operation  even  though  but  temporary  relief  is  obtained. 

Extirpation  of  Tumors  of  Nerves.— Neuromas  are  found  most  fre- 
quently in  amputation  stumps,  forming  bulbous  enlargement  of  the  cut  ends 
of  the  nerve-trunks.  Since  the  introduction  of  aseptic  wound  treatment, 
however,  they  have  been  less  frequently  observed.  They  produce  exquisite 
pain  and  prevent  the  wearing  of  an  artificial  limb.  They  are  dissected  out 
after  the  cicatrix  has  been  split,  the  nerve-trunk  on  which  they  are  situated 
being  divided  as  far  away  from  the  stump  as  possible. 

Neurofibromas  may  occur  singly  or  in  groups.  When  they  occur  singly,  the 
tumor  is  usually  situated  on  the  lateral  aspect  of  the  nerve-trunk.  The  nerves 
of  the  skin  of  the  lower  extremities  are  more  frequently  attacked.  These 
growths  are  exceedingly  painful  and  require  removal.  This  should  be  done 
without  division  of  the  nerve,  particularly  in  the  case  of  important  nerves. 
Multiple  neurofibromas,  particularly  the  form  known  as  plexiform  neuro- 
fibromas, except  when  they  occur  on  the  extremities,  or  on  the  skin  of  the 
tnmk,  are  not  amenable  to  operative  treatment. 

Myomas  of  nerves  are  the  most  important  nerve  tumors  that  come  under 
the  notice  of  the  surgeon.  They  are  soft  masses  consisting  of  semifluid  mucous 
tissue,  the  size  of  a  child's  head;  when  large',  they  are  usually  situated  in  the 
course  of  large  nerve-trunks  and  have  a  feeling  of  pseudofluctuation.  In  some 
instances  the  large  ones  pass  over  the  convex  surface  of  the  tumor,  but  few 
nerve-fibers  invading  the  tumor;  in  other  cases  the  latter  seem  to  be  a  portion 
of  the  tumor  itself.  Paralysis  of  the  nerve-trunk  from  which  they  spring  is  not 
common,  the  nerve-fibers  seeming  to  preserve  their  conductivity  in  spite  of 
their  apparent  involvement  in  the  tumor.  In  the  removal  of  these  growths  such 
nerve-fibers  as  are  distinctly  isolated  may  be  preserved;  otherwise  the  trunk 
must  be  divided  at  the  limits  of  the  tumor  and  the  continuity  of  the  former 
restored  by  a  neuroplastic  operation  (see  page  354). 


OPIOIIATIONS    ON    IMUSCLK.S    AND    TIONDONS  357 

Ncrve=stretching  lias  l)oen  successfully  omj^loyed  in  cases  of  neuralgia  in 
which  huniUcs  of  nerve-hhers  arc  bound  down  to  the  surrounding  connective 
tissue  by  cicatricial  attachments.  The  strong  tension  made  on  the  nerve,  under 
these  circumstances,  results  in  the  stretching  and  the  loosening  of  these  adhe- 
sions. The  method  has  also  been  employed  in  certain  forms  of  neuritis;  it 
has  been  followed  fre(|uently  by  temi)orarv  relief,  and  occasionally  by  cure. 
In  convulsi\'c  tic  douloureux  stretching  of  the  motor  portion  of  the  seventh 
ncv\Q  has  also  been  successful.  This  is  not  a  trustworthy  method  of  treatment 
in  intractable  neuralgia,  prompt  relapse  following  any  improvement  obtained. 
It  is  now  virtually  abandoned  in  tetanus,  tabes  dorsalis,  epilepsy,  and  degen- 
erated processes  in  peripheral  nerves. 

Slight  tension  on  a  nerve  increases  the  reflex  excitability  (S  c  h  1  e  i  c  h), 
while  decided  stretching  is  followed  by  a  temporary  diminution  of  the  excita- 
bility, or  this  may  be  abohshed  altogether  (Valentine).  The  jDaralysis 
which  follows  nerve-stretching  usually  rapidly  disappears.  Nerve-stretching 
may  be  useful,  therefore,  when  a  nerve  is  in  an  excessively  excitable  condition, 
or  when  the  symptoms  are  due  to  an  inflammatory  fixation  or  constriction  of 
the  nerve  at  some  part  of  its  course.  It  has  been  shown  (P.  V  o  g  t)  that  the 
stretching  of  a  nerve-trunk  is  follow^ed  by  dilatation  of  the  vessels  of  the  nerve. 
This  may  give  rise  to  beneficial  nutritive  changes. 

In  most  instances  the  operation  is  applied  to  the  large  nerve-trimks  supply- 
ing the  upper  and  lower  extremities.  The  nerve  is  exposed,  isolated,  and  a 
band  of  gauze  made  by  folding  several  thicknesses  together  which  are  passed 
beneath  the  trunk.  This  is  formed  into  a  loop  by  tying  its  ends  together  and 
is  attached  to  a  Chatillon  spring  balance  scale.  The  tension  is  then  applied 
and  the  amount  of  strain  put  on  the  nerve  noted. 

Breaking  Strain  of  the  Principal  Nerves  in  the  Body.— The  breaking 
strain  of   the  principal   nerves  in  the   body  is  as  follows  (T  r  o  m  b  e  1 1  a) : 

Great  sciatic, 183  pounds 

Internal  popliteal, 114  " 

Anterior  crural, 83  " 

Median, 83  " 

Ulnar  and  radial, 59  " 

Brachial  plexus  in  the  neck, 48  to  63  " 

"  "        axilla, 35  to  81 

In  applying  the  tension  the  strain  must  be  divided,  by  proper  division  of 
the  force,  as  nearly  as  possible  between  the  central  and  the  peripheral  portion 
of  the  nerve. 

So-called  "dry  stretching"  of  a  nerve  consists  of  making  tension  on  the 
nerve  by  means  of  forcible  changes  in  the  position  of  the  parts.  It  is  used 
principally  in  connection  with  the  sciatic  nerve.     (See  Regional  Surgery.) 

OPERATIONS  ON  MUSCLES  AND  TENDONS 

Suture  of  Muscles  and  Tendons.— Subcutaneous  ruptures  of 
muscles  generally  unite  without  operation.  Open  section  of  muscles,  however, 
usually  demands  suturing.  Silk  is  generally  preferred  for  this  purpose;  the 
elasticity  of  the  muscular  tissue  and  its  tendency  to  contract  contraindicate 
the  use  of  catgut.  When  employed  for  suturing  muscles  or  tendons  the  silk 
should  be  as  fine  as  possible,  the  suture  should  not  be  drawn  very  tight,  and  the 
knot  ends  should  be  cut  as  short  as  possible. 


358 


OPERATIONS    ON    INDIVIDUAL    STRUCTURES 


the    muscle 


Traumatic  Separation  of  Tendons. — This  is  of  much  greater  frequency 
than  tlie  above,  owing  to  the  more  exjDosed  situation  of  the  tendons.  The  divided 
ends  recede  at  once  to  a  considerable  distance  in  the  sheath.  If  permitted  to 
remain,  they  become  attached  to  surrounding  structures  and  the  function  of 
is    lost. 

Suture  of  Tendons. — The  tendon  should  be  exposed  by  a 
curved  incision  so  as  to  avoid  a  continuous  cicatrix  between  the 
skin  and  the  tendon.  The  sheath  of  the  tendon  is  split  in  order 
to  secure  the  retracted  ends.  These  are  then  brought  into 
position  and  secured  by  sutures  of  fine  aseptic  silk.  In  broad 
tendons  several  sutures  should  be  applied.  Whenever  possible 
the  ends  should  lap  over  each  other,  as  the  peritendinous  con- 
nective tissue  is  much  more  A^ascular  than  the  tendon  itself. 
The  slight  shortening  which  results  does  not 
interfere  with  the  future  usefulness  of  the  ten- 
don. The  wound  is  closed  and  a  fixed  dressing 
applied  to  support  the  parts  in  a  relaxed 
position. 

Tendoplasty. — This  procedure  is  employed 
when,  either  from  destruction  of  a  portion  of  a 
tendon,  or  in  cases  of  old  injury,  there  is  an 
inability  to  approximate  the  retracted  ends. 
A  flap  is  formed  from  one  end  of  the  divided 
tendon,  turned  down  and  sutured  to  the  other 
stump  (Fig.  139).  If  necessar}^,  in  order  to  fill 
a  greater  defect,  a  similar  flap  may  be  taken 
from  the  other  extremity  also  (Fig.  140). 

Threads  of  catgut  and  aseptic  silk  have 
been  made  to  stretch  across  from  one  stump 
to  the  other  in  cases  in  which  it  was  impossi- 
ble to  bring  these  together.  The  implanted 
material  is  healed  in,  and,  in  case  the  wound  pursues  an 
aseptic  course,  becomes  gradually  absorbed  and  is  replaced  by 
connective  tissue.  A  piece  of  tendon  transplanted  from  a 
lower  animal  will,  if  the  operation  is  successful,  behave  in  the 
same  manner. 

Lengthening  Contractured  Tendons. — A  longitudinal 
incision  is  made  in  the  middle  line  of  the  tendon,  from  each  end 
of  which  a  cross-cut  is  carried  to  the  edge  of  the  tendon  in 
opposite  directions.  The  tendon  is  then  separated,  lengthened, 
and  sutured  as  shown  in  Fig.  141.  Another  method  consists 
in  making  two  parallel  incisions  in  the  tendon,  each  two  inches   ^^°;  i40.— Double 

°         .  J^  .  .  '  rENDOPLASTY. 

long,  one  l^eing  three-eighths  of  an  inch  higher  up  on  the  tendon        Flap  taken  from 
than  the  other.    The  opposite  ends  of  these  incisions  are  carried  lon^  (Trn'ka)°^  *^'^" 
to  the  edge  of  the  tendon  (Fig.   142).     By  traction  the  cen- 
tral portion  is  straightened  out  and  the  tendon  is  lengthened  by  an  amount 
equal  to  the  length  of  the  incisions. 

Vicarious  Tendoplasty. — Failure  to  identify  the  retracted  central  end  of 
a  tendon  constitutes  one  of  the  indications  for  this  procedure.     The  peripheral 


Fig.  1.39. — Method 
OF  Tendoplasty. 


OPERATIONS    OX    .MUSCLES   AND    TENDONS 


359 


inriTtiiniiiviDTii: 


end  is  identified  and  freshened.  The  tendon  of  an  adjoining  muscle  is  now 
spUt.  one  half  of  its  tissue  utilized  for  attachment  to  the  injured  tendon,  the 
other  half  retaining  its  normal  connection.  In  in- 
jury of  the  tendon  of  the  extensor  longus  pollicis 
or  that  of  the  extensor  brevis  pollicis,  the  tendon 
of  the  extensor  carpi  radialis  longior  may  be  split 
longitudinally,  a  flap  turned  down  and  sutured  to 
the  peripheral  stump  of  the  injured  tendon 
(Schwartz).  In  cases  of  old  injury  of  the 
muscles  and  tendons  of  the  forearm  in  which  the 
retracted  ends  cannot  be  brought  together  the 
extensor  communis  digitorum  may  be  split  and  a 
flap  of  the  muscle  itself  turned  down  and  attached 
to  the  peripheral  tendinous  stump  (S  crib  a). 
Tliis  method  may  also  be  employed  in  certain  cases 
of  talipes.  The  divided  peroneal  tendons  may  be 
united  to  the  tendo  Achillis  to  assist  the  action  of 
the   latter    in    paralytic    calcaneus.      In    paralytic 

valgus  the  extensor 
proprius  hallucis  is 
frequently  un- 
affected and  may  be 
employed  to  substi- 
tute its  action  for 
that  of  the  paral- 
yzed tibiahs  muscle 
by  cutting  away  the 
sheaths  of  both  ten- 
dons which  run  side 
by  side,  scarifying 
and  sutm'ing  them 

for  an  inch  or  more,  the  foot  being  strongly 
mverted  so  as  to  shorten  up  the  tendon  of 
the  tibialis  anticus  and  pull  down  the  tendon 
of  the  extensor  haUucis  (P  a  r  r  i  s  h  ,  1892). 
Or.  the  tendon  of  the  extensor  proprius  hallu- 
cis and  the  anterior  tibial  tendon  may  be 
divided,  the  proximal  end  of  the  former  being 
sutured  to  the  distal  end  of  the  latter;  the 
distal  end  of  the  extensor  polUcis  is  united  to 
the  conmion  extensor  of  the  toes. 

Suppurative  Inflammation  in  Sheaths 
of  Tendons. — Rapid  uifection  may  take  place 
by  this  means.     The  sheath  must  be  opened 
up  freely  by  means  of  the  probe  bistoury  and 
thoroughl}''  irrigated   by  means   of    an   anti- 
septic solution;    otherwise  the  necrotic  changes  wiU  destroy  the  tendon  itself, 
or  its  function  will  be  impaired  by  the  formation  of   adhesions  between  the 
tendon  and  the  sheath.      If.  in  order  to  reach  a  deep  abscess,  it  becomes 


Fig.     141. — Lexgthzxtxg    a 
Texdox. 
A,  Method  of  dividing  the 
tendon;    B,  method  of  reunit- 
ing the  tendon. 


Fig.  142. — Texdoplastt. 


360  OPERATIONS    ON   INDIVIDUAL    STRUCTUKES 

necessary  to  pass  through  a  mass  of  muscular  tissue,  this  may  be  advan- 
tageously accomplished  by  first  passing  through  it  a  l)lunt  probe  or  director 
and  then  the  closed  blades  of  a  dressing  forceps,  which  should  be  open  when 
withdrawn,  llie  hemorrhage  which  follows  incision  of  the  muscle  is  thereby 
avoided.  In  following  up  burrowing  pus  the  uterine  repositor  (Fig.  165), 
used  as  a  director  or  probe,  is  introduced  in  case  the  finger  fails  to  reach  the 
extreme  limits  of  the  pus  cavity,  and  the  screw  on  the  handle  turned  until 
the  extremity  of  the  instrument  marks  externally  the  point  where  the  counter- 
opening  is  to  be  made.  The  skin  and  fascia  are  now  incised,  and  the  director 
and  dressing  forceps  relied  on  for  the  rest. 

Myotomy  and  Tenotomy. — The  essential  indication  for  these  operations 
is  the  existence  of  contracture  of  muscular  or  tendinous  origin,  such,  for 
instance,  as  section  of  the  sternomastoid  for  wry-neck  (page  651),  the  tendo 
Achillis  in  paralytic  talij^es  equinus  (see  Regional  Surgery),  as  well  as  various 
contractures  of  cicatricial  and  arthritic  origin.  Prior  to  the  introduction  of 
anesthesia,  tenotomy,  which  is  always  the  preferable  procedure  when  practi- 
cable, was  somewhat  indiscriminately  performed;  at  the  present  time  its 
employment  is  more  restricted.  In  contractures  of  the  knee-joint,  and  par- 
ticularly in  the  early  treatment  of  clubfoot,  forcible  restitution  under  anesthesia 
and  retention  by  proper  means  (see  Regional  Surgery)  have  to  a  great  extent 
replaced  tenotomy. 

The  methods  of  lengthening  contracted  tendons  already  described  have  still 
further  narrowed  the  field  of  simple  transverse  tenotomy. 

Subcutaneous  Tenotomy. — To  S  t  r  o  m  e  y  e  r  and  D  i  e  f  f  e  n  Ij  a  c  h 
we  are  indebted  particularly  for  the  development  of  this  method  of  tenotomy 
(1840-1850).  By  means  of  this  procedure  much  less  risk  of  suppuration  in  the 
wounds  was  incurred.  At  the  present  day,  however,  the  employment  of  aseptic 
precautions  renders  open  tenotomy  an  almost  dangerless  procedure  and  per- 
mits its  employment  in  situations  in  which  injury  to  important  structures 
may  follow  the  subcutaneous  method,  e.  g.,  to  the  subclavian  vein  in  section 
of  the  sternal  attachment  of  the  sternomastoid,  and  to  the  external  popliteal 
nerve  in  division  of  the  tendon  of  the  biceps  flexor  cruris. 

An  anesthetic  should  always  be  employed  in  myotomy  and  tenotomy. 
Otherwise  involuntary  contraction  of  the  muscles  may  embarrass  the  operator. 
The  muscle  should  be  put  on  the  stretch  as  much  as  possible.  The  tenotome 
(Fig.  143)  is  introduced  flatwise,  passed  immediately  behind  the  tendon,  and 
the  latter  is  divided  from  behind  forward  by  short  sawing  movements  of  the 
instrument,  the  operator's  left  thumb  pressing  on  the  tendon  from  without. 
The  operator  is  thus  enabled  to  determine  when  the  edge  of  the  blade 
approaches  the  skin,  and  to  avoid  cutting  the  latter.  The  tendon  will  be  felt 
to  give  way,  if  forcible  restitution  of  the  parts  is  made  at  the  same  time ;  some- 
times this  occurs  with  a  snap  or  jerk,  due  to  rupture  of  the  last  few  fibers.  The 
tenotome  is  then  withdrawn  and  the  wound  closed  by  the  thumb  until  a  com- 
press of  antiseptic  gauze  is  applied  and  secured  in  place  by  a  roller  bandage. 

Operations  for  the  Removal  of  Tumors  of  Tendons. — No  definite  rules 
can  be  laid  down  for  the  removal  of  these  tumors.  Fibromas  may  usually  be 
enucleated  by  splitting  the  muscle  in  the  direction  of  its  fibers.  In  sarcomas 
the  most  careful  dissection  wdll  not  give  immunity  against  recurrence. 

Ganglions  spring  from  the  sheaths  of  tendons  and  may  be  treated  success- 


ori'.HA'riONS    ox    HONKS 


361 


fully  (lurin,<2;  the  first  few  weeks  of  their  existence'  by  means  of  massage  or 
meiliodicalh'  applied  pressure.  'Hie  old  method  of  rupturing  the  sac  by  a 
sliai'i)  blow  wilh  the  back  of  a  book  not  infreciuently  fails  and  is  a  barbarous 
procedure.  Subcutaneous  incision  and  the  pressing  of  the  contents  into  the 
surrounding  conned  ive  tissue,  from  which  they  are  absorbed,  is  preferable. 
'riu>  wall  of  the  sac  may  1)6  scarified  from  within  at  the  same  time.  Pres- 
sure by  means  of  a  compress  and  bandage  is  then  ai)plipd.  Aseptic  incision, 
followed  by  extirpation  of  the  sac  wall,  if  carefully  performed,  is  the  ideal 


Fig.  143. — Tenotomes. 

method  of   dealing  with  these  tumors.     Even  if   small  portions  of   the  sac 
wall  are  left  behind,  recurrences  are  rare. 

^lovable  bodies  occurring  in  tendinous  sheaths,  as  well  as  in  bursae,  may  be 
removed  by  incision.  In  the  case  of  the  latter,  extirpation  of  the  entire  sac 
wall  may  be  indicated  on  account  of  the  usual  coexistence  of  hyperplastic 
synovitis,  in  connection  with  which  some  semisessile  rice  bodies  are  usually 
found  to  exist.  This,  however,  is  not  practicable  in  the  case  of  tendinous 
sheaths. 

OPERATIONS  ON  BONES 

The  Division  of  Bones.— Bones  are  divided  either  by  fracture,  osteo- 
clasis, sawing,  chiseling,  or  cutting. 

Fracture  may  be  accomplished  by  the  hands,  when  the  solidity  of  the 
structure  is  not  too  great  to  permit  the  employment  of  this  method,  or  the 
conformation  of  the  parts  such  as  to  render  it  impracticable  (e.  g.,  insufficient 
leverage,  or  the  interposition  of  thick  muscular  structure  preventing  a  firm 
grasp).  Under  the  latter  circumstances  osteoclasis  or  instrumental  fracture  is 
indicated.     The  most  perfect  instrument  for  the  purpose  is  shown  in  Fig.  144. 

Division  of  Bone  by  Sawing.— Saws  of  different  patterns  have  been 
devised.  The  most  practicable  of  these  are  the  broad  saw  (Fig.  82),  the  frame 
saw  (Fig.  83),  the  kevhole  or  metacarpal  saw  (Fig.  148),  the  chain  saw  (Fig. 
145),  the  wire  saw  of  G  i  g  1  i  (Fig.  147),  and  the  trephine  (Fig.  84).  For  ordi- 
nary amputations  either  of  the  two  first  named  answers.  In  resections_  m 
which  it  mav  be  desirable  to  change  the  direction  of  the  blade  m  order  to  give 
a  certain  conformation  to  the  sawed  surface,  the  frame  saw  with  a  mechanism 


362 


OPERATIONS    OX    IXDIVIDl'AL    STRUCTURKS 


for  accomplishing  this  is  useful.     The  metacarpal  saw  (Fig.  148),  or  keyhole 
saw  as  it   is  sometimes   called,  is  useful  when  it  is  desirable  to  introduce  the 


Fig.  144. — Rizzoli's  Osteoclast. 


instrument  through  a  small  opening  or  to  saw  on  a  curved  line.  A  modifica- 
tion of  this  instrument  for  purjDOses  of  subcutaneous  osteotomy  is  that  known 
as  Adams's  saw  (Fig.  149). 


Fig.   145. — Chain  Saw. 


The  chain  saw  is  led  around  the  bone  by  means  of  the  chain  saw  carrier 
(Fig.  146)  or  a  large  curved  needle.     A  loop  of  silk  is  first  drawn  around  and 


Fig.   146. — Chain  Saw  Carrier. 


to  this  the  saw  is  attached.     The  wire  saw  of  G  igli  has  largely  replaced  the 
chain  saw.     Pinching  in  the  furrow  and  consequent  breakage  of  the  chain  or 


OPERATIONS    ON    BONES 


363 


the  wire  saw  mav  1)o  best  avoided  by  holding  the  handles  of  the  instrument 
wide  apart  in  the  manipulation,  the  saw  thus  describing  a  very  obtuse  angle. 
In  the  manipulation  of  the  broad  and  the  frame  saw  the  heel  of  the  mstru- 
ment  should  be  first  applied  to  the  bone  and  the  act  of  sawing  commenced  by  a 
slow  and  stcadv  drawing  movement  and  strong  pressure.     For  the  rest  of  the 


Fig.  147. — The  Gigli  Wire  S.i.w. 

manipulation  the  usual  to-and-fro  movements  are  executed.  The  assistant  who 
steadies  the  parts  to  be  removed  should  do  this  in  a  manner  which  will  tend 
slio-htlv  to  separate  the  sawed  surfaces,  in  order  to  prevent  the  saw  from 
becomino-  pinched.  Too  great  force  applied  in  this  direction,  however,  should 
be  avoid^'ed.  else  the  bone  will  be  prematurely  broken  before  it  is  sawed  com- 
pletely across. 


Fig.  148. — Met.\carp.\l  Saw. 


In  former  times  great  stress  was  laid  on  the  occurrence  of  necrosis  as  the 
result  of  sawing  the  bones.  The  influence  of  sepsis  and  consequent  mflam- 
matorv  conditions  were  not  properly  appreciated.  It  is  now  known  that  the 
nutrition  of  bone  is  not  easily  destroyed  by  this  means,  if  septic  comphcations 
are  avoided. 


Fig.  149. — Adams's  Saw. 

Division  of  Bones  by  Chiseling.-Chisels  are  made  either  tapering  or 
wedo-e-shaped  (M  a  c  e  w  e  n,  Fig.  89),  with  beveled  edges,  or  hoUowed  out^on 
one  surface  (gouges) .  The  latter  may  sometimes  be  used  as  hand  gouges.  The 
usual  method  of  usmg  the  chisel,  however,  is  in  connection  with  the  mailet 
(Fio-    150)    which  is  preferablv  made  of  lignum-vitae  or  other  hard  wood. 


364 


OPERATIONS    OX   IXDIVIDUAL   STRUCTURES 


Where  a  simple  straight  cut  is  to  be  made,  particularly  in  the  cancellous  struc- 
ture of  bone,  as  in  supramalleolar  osteotomy  (M  a  c  e  w  e  n),  the  wedge- 
shaped  or  tapering  chisel  is  to  be  preferred.  To  prevent  "binding/'  as  the 
instrument  advances  into  the  depths  of  the  bone,  a  more  bluntly  shaped 
instrument  is  at  first  emploj'ed;  this  is  subsecjuently  followed  by  one  less 
blunt,  and  finally  by  a  comparative^  slender  instrument. 

In  cutting  away  portions  of  bone  the  beveled  chisel  is  to  be  used.  It  is  held 
at  a  ver}'  obtuse  angle  to  the  bone,  in  order  to  cut  away  wedge-shaped  pieces. 
The  V-shaped  groove  which  is  thus  produced  may  be  "sciuared"  at  each 
margin  of  the  cut  before  completing  the  section.     The  chisel  must  not  be  held 


Fig.  150. — Bone  Chisel  axd  Mallet. 

too  firmly,  else  a  portion  of  the  force  of  the  blow  will  be  lost.  Neither  must  it 
be  held  too  loosely,  or  it  may  deviate  from  the  course  intended.  When  thin 
slices  are  to  be  removed  parallel  to  the  surface,  the  bevel  side  of  the  instrument 
is  to  be  placed  next  to  the  bone. 

With  the  acquirement  of  skill  in  the  manipulation  of  the  chisel  and  mallet 
the  surgeon  will  be  enabled  to  substitute  these  for  the  trephine  almost  entirely 
(see  page  444). 

Division  of  Bone  by  Cutting  Forceps. — Though  bone  in  its  very  young 
state  and  in  certain  pathologic  conditions  may  be  divided  by  means  of  the  knife 
or  scissors,  bone-cutting  forceps  are  usually  employed  for  this  purpose.  These 
are  made  in  several  patterns,  those  of  L  i  s  t  o  n  and  L  u  e  r  (see  page  317) 


Fig.   151. — The  Sharp  Spoox. 


being  the  best  known.  The  first  named  have  plain  cutting-edges  which  meet 
instead  of  passing  each  other,  as  in  the  case  of  scissors.  L  u  e  r '  s  forceps  are  also 
known  as  the  rongeur.  A  well-made  L  i  s  t  o  n  forceps  may  be  advantageously 
substituted  for  the  metacarpal  saw  in  dividing  such  small  bones  as  those  of  the 
metatarsal  and  metacarpal  regions,  as  well  as  in  making  the  section  of  the  ribs 
in  Estlander's  operation  of  thoracoplasty.  The  rongeur  forceps  (Fig.  90,  A) 
may  be  used  as  an  adjunct  to  other  bone-cutting  instruments,  as,  for  instance,  in 
cutting  away  the  small  toothlike  projections  left  on  sawed  or  chiseled  bones. 
The  sharp  spoon  (Fig.  151)  is  also  employed  in  cutting  bone,  somewhat  in 
the  same  manner  as  the  hand  gouge.     It  is  much  more  effective  than  the  latter, 


OPinjATIoXS    oX    BOXES 


365 


however.     It  has  been  improved  so  as  to  permit  of  simiihaneoiis  cutting  and 
irrigating;  (Fig.  94). 

Coaptation  of  Bone  by  Operati>e  Weans. — Laterally  placed  openings, 
as,  for  in.^tance.  tho.se  produced  in  the  operation  of 
sequestrotomy  (j^age  369),  will  not  permit  approxima- 
tion of  the  edges  of  the  opening.  In  certain  joint 
resections,  in  which  transverse  sections  of  the  bone 
have  been  matle.  it  may  be  undesirable  to  promote 
union  of  the  sawed  surfaces  directly  (subperiosteal  re- 
section). The  simple  application  of  a  retention  ban- 
dage, and  perhaps  the  application  of  extension,  is  here 
indicated.  In  cases  in  which  imion  is  desired  and  the 
fixed  dressings  are  not  sufficient  to  insure  coaptation  of 
the  fragments,  operative  fixation  is  indicated.  In  ac- 
complishing tills  the  method  of  mortise  coaptation  is 
sometimes  employed  (Fig.  152). 

Bone  Suture. — This,  when  properly  applied,  will 
accomplish  all  that  can  be  accomplished  in  operative 
fixation  of  the  fragments.  It  should  replace  the  meth- 
ods of  clamping,  the  use  of  metal  plates,  rods,  and  steel 
screws,  and  pegs  of  metal  and  ivory,  etc.  The  follow- 
ing points  should  be  borne  in  mind:  (1)  The  entire 
limb,  except  the  site  of  the  operation,  must  be  care- 
fully bandaged  with  a  sterile  bandage  in  order  to  main- 
tain asepsis  durmg  the  operation;  (2)  the  incision 
should  be  no  larger  than  necessary  and  the  parts  must 
be  carefuUy  manipulated  in  order  to  prevent  further 
devitaUzation.     Forcible  protrusion  of    the  bone  from 


Fig.  152. — Mortise  Coaptatiox  of  Boxe   with  Ivort  Pegs. 


Fig.  153. — Bevel-gear 
BoxE  Drill. 


the  depths  is  to  he  discouraged;  the  operator  should  work  by  the  sense  of  feel- 
ina;  as  much  as  possible. 


Fig.  154. — Jeweler's  Drill. 


The  instmments  reciuired  are  (1)  a  proper  drill  (Figs.  153  and  154);  (2)  a 
hook  for  drawing  the  suture  through  the  holes;  (3)  several  stout  strands  of 
silkworm-gut  to  serve  as  "leaders,"  or  light  copper  wire  for  the  same  purpose; 


366 


OPERATIONS    ON   INDIVIDUAL   STRUCTURES 


Fig.  155. — A,  Faulty  Method  of  Applying  the 
Bone  Suture;  B,  Correct  Method  (after 
Wille). 


(4)  forceps  to  twist  the  wire  and  a  wire  cutter.  A  narrow  and  pointed  meta- 
carpal saw  may  be  needed. 

In  the  application  of  the  wire  the  following  points  in  the  technic  must  be 
observed  in  order  to  obtain  the  best  results : 

1.  The  shorter  the  distance  be- 
tween the  drill  holes  consistent  with 
securing  a  firm  hold  on  the  fragments, 
the  less  will  be  the  chances  of  subse- 
quent displacement. 

2.  The  line  of  traction  or  the  bind- 
ing force  of  the  suture  must  be  placed 
as  nearly  as  possible  at  right  angles  to 
the  line  of  fracture.  This  is  easily 
accomplished  when  the  drill  holes  are 
properly  placed  (Fig.  155,  B).  In 
oblique  fractures  this  will  naturally 
remove  the  drill  holes  from  the  mid- 
dle line  of  the  bone  (Fig.  156,  A); 
otherwise  the  very  undesirable  effect 
shown  in  Fig.  157  will  be  produced. 
In  very  obliciue  fractures  there  may 

not  be  room  enough  for  the  drill  holes,  in  which  case  a  wire  sling  may  be 
placed  tightly  around  both  fragments  so  as  to  bring  the  binding  force  in  the 
proper  direction ;  grooves  are  made  in  the  bone  with  the  metacarpal  saw  in 
which  to  engage  the  wire  (Fig.  156,  B). 

Another  method  of  securing  a  very  oblique  fracture  is  shown  in  Fig.  158,  A. 
The  fragments  are  brought  into  align- 
ment and  both  drilled  vertically  in  the 
center  of  the  fracture  surfaces.  The 
silver  wire  is  now  passed  to  its  middle 
behind  the  bone,  and  its  "bite"  caught 
by  a  hook  or  leader  passed  through  the 
holes.  The  wire,  doubled  upon  itself, 
is  drawn  through  on  the  withdrawal  of 
the  hook.  By  dividing  the  loop  thus 
formed,  after  it  is  drawn  through,  two 
separate  and  permanent  binding  sutures 
are  formed  (Fig.  158,  B)  (Wille  ; 
H  e  n  n  e  q  u  i  n) . 

Operations  on  Bones  after  Frac= 
tures. — Some  of  the  procedures  dis- 
cussed in  the  foregoing  may  be  neces- 
sary after  fracture.  In  addition,  some 
special  operations  are  required,  particu- 
larly   in   fractures    complicated    by   an 

externally  communicating  wound  (compound  fracture,  accompanied  or  other- 
wise by  extensive  comminution). 

In  extensive  extravasations,  even  in  subcutaneous  fracture,  it  will  occa- 
sionally be  necessary  to  make  an  incision  and  turn  out  the  clot.     This  should 


Fig.  156. — A,  Proper  Method  of  Applying 
the  Bone  Suture  in  Oblique  Fracture; 
THE  Drill  Holes  are  Placed  in  such 
A  Manner  that  the  Wire  Suture  is 
AT  Right  Angles  to  the  Line  of  Frac- 
ture; B,  Sling  Suture  Applied  to  an 
Oblique  Fracture  (after  Wille). 


OPERATIONS    ON    BONES 


367 


Fig.  157. — A,  Faulty  Method  of  Applying  the  Bone  Suture 
IN  Oblique  Fracture;  B,  Mechanism  of  Possible  Dis- 
placement of  the  Fragments  in  Faulty  Method  of 
Bone  Suture  in  Oblique  Fracture  (after  Wille). 


be  resorted  to  only  in  extreme  cases,  such  as  urgent  hemarthrosis  of  the  knee- 
joint  comphcating  fractures  of  the  patella.  Ordinarily  in  blood  extravasations 
about  fractured  bones,  unless  the  supervention  of  high  fever  and  increasing 
sensibility  of  the  part  leatl- 
ing  to  a  suspicion  of  sejisis 
demand  interference,  it  is 
better  to  wait  patiently  for 
nature's  efforts  at  resorp- 
tion. If  incision  is  made, 
the  most  rigid  aseptic  pre- 
cautions and  antiseptic 
treatment  are  necessary. 

In  comi^ound  fractures, 
in  addition  to  the  indica- 
tions offered  by  the  reciuire- 
ments  of  aseptic  and  anti- 
septic measures,  drainage, 
and  the  removal  of  foreign 
bodies,  it  may  become 
necessary  to  remove  isolated 
portions    of   bone.      Under 

these  circumstances  every  effort  must  be  made  to  preserve  as  much  of  the 
periosteum  as  possible.  In  separating  the  fragments  from  the  periosteum  the 
elevator  (Fig.  159)  will  be  found  useful.  In  oblique  fractures,  not  com- 
minuted, one  of  the  fragments  may  project  from  the  wound  and  require  removal 

in  order  to  effect  reduction.     So-called 
^tf^^  \  (  ^"fP^  ^    diaphysial    resection    should    not    be 

^Bil^  JV  k^  ^^'^^- -■     A   resorted  to,  on  account  of  the  large  de- 

fect remaining,  except  under  the  most 
urgent  circumstances.  In  case  of  frac- 
ture extending  into  a  joint  the  projec- 
tion of  a  portion  of  the  latter  through  a 
wound  of  the  soft  parts  may  require  re- 
section. 

Operations  for  Ununited  Frac- 
tures.— The  conditions  existing  under 
these  circumstances  vary  considerably 
and  methods  of  treatment  must  be 
adopted  in  accordance  with  the  require-  ^ 
ments  of  individual  cases. 

Delayed  Union. — Percussion  of  the 

soft    parts    over    the    seat   of    fracture 

(Thomas)  by  means  of  the  handle  of 

a  percussion  hammer,  a    rubber   faced 

mallet,  or  other    instrument,  the   parts 

being  protected   from  direct   injury  by 

a  folded  compress,  will  fulfil  the  indications  in  a  certain  proportion  of  cases. 

A  daity  seance,  or  thrice  weekly  seances  of  from  five  to  ten  minutes,  until 

decided  reaction  is  established,  should  be  prescribed;  if  necessary,  ether  may  be 


Fig.  158. — A,  Method  of  Securing  the  Frag- 
ments of  an  Oblique  Fracture  in  Posi- 
tion BY  Means  of  a  Loop  Suture  Passed 
through  Both  Fragments;  B,  the  Loop 
Suture  Divided  and  the  Two  Halves  of 
the  Loop  Twisted  Together  (after 
Wille). 


368  OPERATIONS    OX    INDIVIDUAL    STRUCTURES 

administered.  The  liml)  is  kept  in  a  fixed  bandage  in  the  intervals.  When 
consideral)le  tenderness  and  some  swelling  have  supervened,  a  plaster-of-Paris 
bandage  should  be  applied  so  as  to  maintain  exact  inm-iobilization  for  three 
or  four  weeks.  This  failing,  rubbing  the  fragments  together  under  an 
anesthetic  may  be  tried.  Needling  after  the  method  of  .^  t  a  r  k  e  (the 
introduction  of  a  stout  needle  or  an  awl,  and  its  manipulation  aljout  the  ends 
of  the  fragments  in  order  to  produce  effusion)  may  accomplish  the  object. 

Ah  of  these  methods  failing,  a  condition  of  pseudarthrosis  exists,  for  which 
the  following  methods  of  treatment  have  been  resorted  to,  in  addition  to  those 
above  described: 

1.  Implantation  of  Ivory  Pegs. — In  this  operation  two  small  incisions 
are  made,  one  above  and  the  other  l^elow  the  seat  of  fracture,  and  a  conical  ivory 
peg  driven  into  each  of  the  fragments  a  short  distance  from  the  seat  of  fracture. 
Reposition  and  retention  follow.  If  the  procedure  is  accomplished  without 
aseptic  precautions,  union  may  be  secured,  but  at  great  risk  from  septic  con- 
ditions. If  strict  aseptic  precautions  are  observed  in  the  treatment,  the  chances 
of  success  are  remote,  owing  to  the  very  slight  reaction  which  follows. 

2.  Resection  of  the  Fractured  Surfaces. — This  method,  combined  with 
bone  suture  following  the  resection,  is  comparatively  devoid  of  danger  under 
aseptic  conditions  and  offers  the  advantage  of  inspection  and  recognition  of  the 
conditions  present,  such  as  the  interposition  of  soft  parts,  as  well  as  the 
opportunity  for  the  removal  of  these.     The  ends  of  the  fragments  are  exposed, 


Fig.  159. — Periosteal  Elevator. 


a  cuff  of  periosteum  turned  back  from  each,  the  surfaces  of  the  former  sawed 
off  so  that  they  will  make  proper  support  for  each  other,  and  the  cuffs  of  peri- 
osteum sewed  together  with  catgut.  A  fixed  dressing  is  applied,  the  external 
wound,  if  asepsis  has  been  preserved,  being  closed.  Bone  suture  may  be  added 
to  the  periosteal  suture.  Whatever  method  may  be  indicated  in  individual 
cases,  the  periosteum  must  be  preserved.  The  slight  production  of  callus 
from  the  medullary  tissue  is  insignificant,  compared  with  that  furnished  by 
the  periosteum. 

Bone  Transplantation. — In  cases  in  which  pseudarthrosis  is  due  to 
a  long  defect  from  considerable  loss  of  osseous  substance,  after  necrosis 
for  instance,  bone  transplantation  (N  u  s  s  b  a  u  m)  is  indicated.  By  means 
of  the  chisel  a  piece  of  bone,  still  attached  to  its  periosteum,  is  loosened  and 
brought  around  so  as  to  bridge  over  the  gap.  The  pedicle  of  periosteum  is 
twisted  upon  itseh.  Or,  a  bone  flap  may  be  obtained  by  splitting  an  adjoining 
bone  and  bringing  this,  still  attached  by  its  periosteum  (the  muscular  and 
fascial  attachments  of  the  latter  being  preserved  as  well),  into  position  so  as  to 
fiU  the  gap.  The  bone  flap  thus  transplanted  must  accurately  fill  the  defect. 
The  method  is  not  applicable  to  pseudarthrosis  without  l^ony  defect. 

Operations  in  Inflammation  of  Bone.— Immediately  on  the  recur- 
rence of  suppuration,  incision  and  drainage  are  indicated.  In  case  of  sup- 
purative foci  in  the  medullary  canal,  the  bone  is  to  be  chiseled  away  in  order 


opi;i;a'I'I()Ns  on  bonks 


569 


lo  ostalilish  (lraiiiai;(\  or  tlio  .softened  corticiil  lamella  may  be  ]ierforated  with 
1  he  |)(iiiits  1)1'  a  closed  anatoiiiic  forceps.  The  sharp  spoon  is  applied,  all  granu- 
latina;  material  scrapetl  away,  and  gauze  drainage  employed.  In  acute  sup- 
purative myelitis  incision  and  drainage  will  frequently  give  better  results,  if 
applied  sulhciently  early,  than  extensive  resection  or  removal  of  the  entire  bone. 
When  delayed,  howe^'er,  sequestra  and  an  involucrum  form  and  require  the 
operation  of  sequestrotomy.  Myelitis  granulosa  differs  from  acute  suppura- 
tive myelitis  by  producing  suppuration  more  slowly.  The  slow  formation  of  the 
resulting  abscess  usually  delays  operative  interference.  When  these  abscesses 
arc  situated  centrally,  their  situation  is  first  determined  by  exploratory 
drilling;  the  opening  thus  made  is  subsequently  to  be  enlarged  by  means  of  the 
chisel  and  mallet . 

Sequestrotomy. — Sequestra  involving  the  cortex  only  may  be  removed  as 
soon  as  formed ;  those  involving  the  entire  thickness  of  the  bone  should  be  per- 
mitted to  remain  until  an  encasement  of  new  bone  has  formed  about  the  diseased 
portion,  unless  profuse  suppuration  which  threatens  life  compels  interference. 

E  s  m  a  r  c  h  '  s  bandages  should  be  applied.  The  fistulous  opening  leading 
down  to  the  diseased  bone  is  enlarged  by  means  of  the  probe-pointed  bistour\\ 
The  site  of  the  cloaca  is  now  investigated.  This  is  enlarged  by  pushing  back 
the  periosteum  and  chiseling  away  its  edges  with  the  gouge  and  mallet.     Two 


Fig.  160. — Sequestrum  Forceps. 


cloacae  situated  near  each  other  may  be  connected.  If  the  examination  dis- 
closes an  entirely  movable  sequestrum,  this  may  be  removed  at  once  by  means 
of  the  sequestrum  forceps  (Fig.  160)  or  the  elevator  (Fig.  159).  Or  the  seques- 
trum may  be  removed  after  being  divided.  This  failing,  a  large  portion  should 
be  chiseled  away  to  permit  the  passage  of  the  detached  portions.  The 
ingenuity  of  the  surgeon  will  be  able  to  overcome  the  mechanic  difficulties; 
as  little  as  possible  of  the  involucrum  of  new  bone  should  be  sacrificed,  though 
equal  care  is  to  be  exercised  in  the  removal  of  all  diseased  bone.  A  repetition 
of  the  operation  is  frequently  necessary. 

The  incised  soft  parts  are  sutured  and  the  cavities  drained  after  thorough 
antiseptic  irrigation.  Insufflation  of  iodoform  powder  or  of  salicylic  acid  is 
sometimes  practised  with  benefit. 

Excavation  of  Bone;  Evidement. — This  operation  is  employed  in  the 
treatment  of  caries  resulting  from  myelitis  granulosa.  The  focus  of  inflam- 
mation and  suppuration  is  to  be  sought  for  through  the  fistulous  canals,  if  such 
exist,  and  made  accessible  for  purposes  of  thorough  removal  by  means  of  the 
sharp  spoon  of  all  products  of  disease  from  the  medullary  canal,  as  well  as  the 
broken-down  osseous  structures.  Small  foci  are  sometimes  scattered  through  the 
otherwise  healthy  appearing  marrow;  only  complete  removal  of  this  will  insure 
a  complete  cure.     In  some  instances  nothing  but  the  sheet  of  cortical  substance 

and  the  articular  extremities  of  the  bone  are  left.     It  is  sometimes  supple- 
25 


370  OPERATIONS    ON   INDIVIDUAL   STRUCTURES 

mented  by  the  application  of  the  actual  cautery  to  the  .site  of  the  primary  focus. 
If  the  cortical  lamellae  are  affected,  evidement  may  not  suffice,  and  partial  or 
total  resection,  or,  in  the  case  of  short  bones,  c.  g.,  the  metatarsal  and  meta- 
carpal bones,  extirpation  may  be  necessary.  If  a  joint  is  found  to  be  invaded, 
this,  too,  must  be  attacked.  After  resection  the  sawed  surface  is  to  be  carefully 
examined  and  all  suspicious  looking  points  scraped  out  with  the  sharp  spoon. 
Evidement  and  sequestrotomy  are  frequently  combined,  as  in  tuberculous 
ostitis,  though  amputation  must  frequently  replace  both  these  and  resection, 
as,  for  instance,  when  several  bones  and  joints  of  the  tarsus  are  simultaneously 
involved,  when  general  miliary  tuberculosis  or  amyloid  degeneration  of  internal 
organs  is  threatened.  In  elderly  persons,  in  ^\  hom  the  periosteum  rarely  regener- 
ates bone,  amputation  is  to  be  preferred,  as  a  rule,  to  the  more  conservative 
procedures. 

Operations  for  Tumors  of  Bone. — The  variety  of  osteoma  which  is 
attached  to  otherwise  healthy  bone  by  a  narrow  base  or  pedicle  (exostosis) 
is  removed  by  being  completely  exposed  and  either  sawed  off  or  chiseled  away. 
In  exostoses  having  a  broad  base,  the  mallet  and  chisel  are  employed.  It  is 
sometimes  necessary  to  make  a  transverse  section  of  the  bone  itself,  in  order 
to  remove  the  growth  comjDletely. 

Chondromas. — These  may  spring  from  the  cortical  lamella  or  from  the 
medullary  cavity.  They  are  usually  adherent  by  a  broad  base.  The  former, 
as  a  rule,  may  be  removed  by  the  knife.  The  latter  are  either  lifted  out  of  the 
medullary  substance,  or  resected,  as  in  osteoma.  Complete  removal  is  not 
always  necessary.  A  removal  of  a  portion  of  the  tumor  sometimes  results  in 
ossification  of  the  remainder,  particularly  when  the  tumor  springs  from  the 
medullary  cavity.  In  the  case  of  an  important  bone  partial  removal  should 
be  tried  before  resection  or  amputation  is  resorted  to. 

Malignant  disease  of  bone  is  represented  by  sarcomas  and  secondary 
carcinomas.  The  most  common^  observed  are  the  sarcomas,  originating 
either  in  the  medullary  structure,  in  the  periosteum,  or  in  the  immediately 
adjacent  soft  parts.  The  operative  indication  for  these  conditions  is  amputation 
or  disarticulation.  The  bone  that  is  the  seat  of  the  disease,  together  with  its 
attached  soft  parts,  must  be  entirely  removed.  Even  this  does  not  give 
immunity  against  recurrence.  The  prognosis  in  the  sarcoma  of  pregnancy 
is  much  more  favorable.  Recurrence,  except  in  subsequent  pregnancy,  is  not 
frequent.  In  epulis  at  the  alveolar  processes  of  the  jaw  resection  of  the  portion 
of  jaw  gives  favorable  results. 

Fibromas  of  bone  are  comparatively  rare  and  indicate  extirpation  of  the 
tumor.  Echinococci  of  bone  are  exceedingly  rare;  they  require  incision  and 
extirpation  of  the  sac. 

OPERATIONS  ON  JOINTS 

Operations    on    Joints    after    Injury. — Puncture    of    the    capsule 

is  sometimes  required  in  hemarthrosis,  particularly  in  that  of  the  knee-joint 
occurring  in  fracture  of  the  patella,  the  repair  of  the  latter  being  facilitated 
thereby.  Usually,  however,  the  effused  blood  is  resorbed  without  difficulty. 
In  hydrarthrosis  puncture  of  a  joint  is  more  frequently  required.  The  opera- 
tion should  always  be  performed  under  the  most  stringent  asepsis.  If  there  is 
not  much  tension  present,  the  left  hand  of  the  operator  forces  as  much  as 


OPERATIONS    OX    JOINTS  371 

possible  of  \ho  (luiil  in  the  joint  toward  the  i)lace  of  intended  puncture.  The 
trocar  employed  should  he  suflici(>ntly  large  to  permit  the  free  passage  of  thick- 
ened synovia.  If  antiseptic  irrigation  of  the  joint  is  indicated,  this  can  be 
accomplished  through  the  trocar,  solutions  of  carbolic  acid  (1  :  40),  corrosive 
sublimate  (1  :  2000),  or  salicylic  acid  (1  :  200)  being  employed.  The  irrigating 
fluid  is  forced  into  all  parts  of  the  joint  by  external  manipulations  and  the  joint 
thoroughly  washed  out  l)y  repeat(Mlly  filling  and  emptying  it. 

Incision  and  Drainage  of  Joints. — These  two  procedures  combined  are 
most  frequently  indicated  by  the  occurrence  of  suppuration  of  joints  after 
traumatism  and  infection,  suppuration  from  any  other  cause  (pyarthrosis  from 
polyarthritis,  synovitis,  gonococcus  infection),  or  from  an  extension  of  an 
acute  osteomyelitis  to  an  adjacent  joint.  In  granular  synovitis  (tubercu- 
lous) the  procedure  is  useless. 

The  first  incision  must  be  sufficiently  long  to  pemiit  digital  exploration 
of  the  joint.  Other  and  smaller  openings  (counter-openings)  may  be  made 
when  the  condition  of  the  joint  is  ascertained.  The  exploration  should  take 
cognizance  of  the  condition  of  the  cartilages  with  reference  to  the  presence  of 
necrosis;  of  the  bone  with  reference  to  the  presence  of  fissures  or  splintered 
fragments,  sequestra,  etc.;  it  likewise  determines  the  most  available  points  for 
locating  the  counter-openings.  Dressing  forceps  introduced  into  the  joint  and 
their  l^lades  then  separated  form  the  best  guide  on  which  to  make  the  incisions 
for  the  counter-openings.  They  are  likewise  utihzed  by  being  passed  through 
the  incision  for  the  purpose  of  drawing  the  drainage-tube  into  position. 

In  large  joints  and  extensive  suppuration  through-and-through  drainage  is 
best,  a  long  tube  being  led  through  the  whole  joint  cavity. 

The  attempt  to  drain  a  joint  b}'  means  of  a  rubber  drainage-tube  introduced 
through  the  cannula  employed  in  making  a  puncture  is  not  to  be  recommended. 

Incision  alone  may  be  employed  for  diagnostic  purposes,  but  should  be 
restricted  to  conditions  in  which  strict  asepsis  is  possible  and  where  the  incision 
may  be  utilized  for  therapeutic  purposes.  The  operation  is  also  indicated  for 
the  removal  of  joint  villi  and  free  movable  bodies  in  the  joint. 

Resection  of  Joints. — The  general  indications  for  resection  of  joints 
are  as  follows: 

1.  Compound  dislocations.  Here  the  choice  will  be  between  removal  of 
splintered  portions,  reduction  of  the  dislocation  and  drainage,  or  primary 
resection.  The  circumstances  in  each  case  must  be  carefully  taken  into 
account,  particularly  with  reference  to  the  establishment  and  maintenance 
of  aseptic  conditions. 

2.  Extensive  and  severe  suppurative  conditions  consequent  on  in- 
jury. Resections  performed  under  these  circumstances  are  either  inter- 
mediate or  secondary,  according  to  the  period  of  time  intervening  between 
the  injury  and  their  performance. 

3.  Suppuration  occurring  in  connection  with  tuberculous  synovitis  and 
myelitis.  While  it  cannot  be  said  that  every  tuberculous  focus  in  joints 
demands  operative  interference,  owing  to  the  fact  that  the  suppurative  process 
tends  to  limit  the  specific  infection,  greater  security  against  general  infection  is 
obtained,  other  things  l^eing  equal,  by  resection  of  the  parts  containing  the 
tuberculous  focus.  Even  after  apparent  recovery  in  cases  not  operated  on, 
recurrence  is  to  be  feared. 


372  OPERATIONS    ON    INDIVIDUAL    STRUCTURES 

4.  Granular  synovitis  without  suppuration,  nonoperative  treatment 
proving  unavailing,  furnishes  an  indication  for  resection.  The  presence  of 
granular  myelitis  is  an  indication  for  early  resection,  a  l:)etter  functional 
result  following  this  than  when  the  interference  is  delayed,  inasmuch  as  the 
sheaths  of  the  tendons  are  still  unchanged  and  the  nutrition  of  the  muscles 
comparatively  unimpaired.  Arthrectomy  {vide  infra)  is  followed  by  prompt 
and  satisfactory  results,  in  cases  of  synovial  tul^erculosis,  pure  and  simple. 

5.  Contractures  and  ankylosis,  in  case  nonoperative  treatment  is  of  no 
avail,  may  be  submitted  to  resection.  In  ankylosis  a  most  positive  indication 
is  offered  by  a  functionally  useless  position  of  the  parts,  e.  g.,  a  knee-joint  in 
the  flexed  position,  or  an  elbow-joint  in  the  extended  position.  Old  disloca- 
tions, if  they  cannot  be  reduced  in  the  ordinary'  manner,  require  resection, 
both  to  increase  the  range  of  movement  and  to  relieve  functional  dislocations 
arising  from  pressure.  Arthrodesis,  designed  to  produce  a  rigid  condition 
of  the  joint  in  certain  muscular  paralyses  and  flail-like  joints  (infantile 
paralysis),  involves  resection  of  the  joint  surfaces  (seepage  373). 

The  justification  for  the  performance  of  resection  for  the  sole  purpose  of 
restoring  function  to  otherwise  useless  parts  is  to  be  sought  for,  in  each 
individual  case,  in  the  desire  on  the  part  of  the  patient  to  have  his  condition 
improved,  and  in  a  prior  understanding  as  to  all  possible  results  of  the 
operation  itself. 

Immediate  resection  is  rarely  performed  in  grave  injuries.  The  oppor- 
tunities of  coml^ating  sepsis  justify  waiting  for  shock  to  subside.  Primary 
resection  is  performed  after  the  shock  of  the  injury  has  subsided  and  before 
septic  complications  set  in.  This  period  covers  from  twenty-four  to  forty- 
eight  hours  after  the  injury.  Intermediate  resection  is  preferred  after  septic 
complications  have  set  in  and  while  these  are  in  existence.  By  facilitating 
drainage  and  rendering  accessible  remote  suppurating  foci  and  collections  of 
pus,  resection  in  this  period  assists  in  overcoming  sepsis.  Secondary  resec- 
tion is  performed  after  sepsis  subsides.  Its  uses  are  to  remove  diseased  bone; 
to  overcome  deformity;  to  relieve  extreme  pain  or  loss  of  function  in  a  part. 
It  may  likewise  be  necessary  because  of  the  presence  of  persistent  sinuses. 

Partial  Resection. — ^lany  surgeons  prefer  partial  resection.  This  may 
be  indicated  in  certain  acute  joint  injuries  under  conditions  where  an  aseptic 
wound  course  may  be  confidently  expected.  Even  here,  the  projecting  artic- 
ular extremity  of  the  bone  into  the  cavity,  as,  for  instance,  the  presence  of 
the  lower  extremity  of  the  femur  after  removal  of  the  head  of  the  tibia,  and  of 
the  humerus  after  removal  of  the  ulna,  may  interfere  with  free  drainage  and 
aseptic  treatment.  Partial  resection  is  not  admissible  as  an  intermediate 
or  secondary  operation  and  it  is  usually  contraindicated  in  granular  synovitis 
and  myelitis.  In  the  majority  of  instances  it  will  therefore  give  way  to  total 
resection. 

Erasion  or  arthrectomy  (V  o  1  k  m  a  n  n)  is  a  variety  of  partial  resection. 
It  consists  in  opening  the  joint  and  cutting  or  scraping  away  all  diseased  tissues, 
these  including  both  the  synovial  structures  and  the  joint  ends  themselves.  It 
is  particularly  applicable  to  the  cases  of  tuberculous  joint  disease  of  childhood 
in  which  the  granulating  inflammation  takes  its  origin  in  the  synovial  structure 
and  is  limited  to  that  membrane.  In  this  class  of  cases  total  resection,  by 
interfering  with  the  epiphysis,  restricts  the  relative  growth  of  the  corresponding 


OPERATIONS    ON    J(HNT,S  373 

liiiil).  Special  caro  must  bo  exercised  in  selecting  cases  for  erasion,  in  order 
that  promiit  and  ri'ix'ated  i-ccuitcmicc  may  be  avoided. 

The  General  Technic  of  Joint  Resection. — Incisions  in  the  soft  parts  are 
usually  made  in  the  longitudinal  axis  of  the  limb  and  are  so  located  as  to  avoid 
injury  to  temlinous  and  muscular  structures.  This  rule  may  be  deviated  from 
at  times  in  cases  of  granulating  synovitis  and  myelitis,  and  particularly  in 
resection  of  the  head  of  the  humerus  and  of  the  femur. 

The  parts  are  incised  by  a  knife  with  a  broad  blade  and  a  large  handle. 
Large  nerve-trunks  and  important  blood-vessels  are  to  be  avoided.  The  drains 
are  so  located  as  to  reach  the  deepest  portion  of  the  wound  cavity  and  are 
placed  in  a  position  in  which  gravity  will  assist  in  carr3dng  off  the  wound 
secretions. 

When  the  resection  is  performed  for  granulating  synovitis  and  myelitis,  the 
capsular  covering  is  necessarily  sacrificed.  Where  the  capsule  is  healthy,  one 
or  two  longitudinal  incisions  are  to  be  made  in  the  synovial  membrane;  this 
is  dissected  loose  and  turned  aside  to  permit  the  sawing  away  of  the  bone 
underneath  (subcapsular  resection).  Further,  subperiosteal  resection  is 
likewise  to  be  employed  wherever  practicable.  In  the  latter  the  periosteal 
covering  is  to  be  incised  and  turned  back  in  the  shape  of  a  cuff  to  the  extent 
of  the  intended  removal  of  bone.  The  adjoining  muscular  and  tendinous 
structures  should  be  pre- 
served in  their  attach- 
ment to  the  periosteum 
as  far  as  possible.  In 
cases  of  old  inflammation 
this  is  comparatively  eas- 
ily accomplished.  In  re- 
cent   injuries,     old     luxa-  ^ig.  161.-Lionwaw  Forceps. 

tions,  and  ankylosis  cases 

it  is  not  possible,  oftentimes,  to  make  a  completely  subperiosteal  resection. 
In  these  difficult  cases  it  is  occasionally  possible  to  lift  a  layer  of  the  outer 
lamella  of  the  bone  with  the  periosteum.  When  it  is  borne  in  mind  that 
subperiosteal  resection  preserves  the  branches  of  the  rete  arteriosum  of  joints, 
prevents  suppuration  in  the  synovial  sheaths  of  the  tendons,  as  well  as  in  the 
connective-tissue  planes  in  the  neighborhood  of  the  joint,  and  secures  the 
formation  of  new  articular  extremities,  the  necessity  of  adopting  it  in  every 
case  in  which  it  is  indicated  or  possible  is  apparent.  Every  strip  of  perios- 
teum capable  of  being  utilized  should  be  preserved.  Bony  prominences  which 
serve  as  attachments  for  muscles  may  be  chiseled  off  and  left  attached  to  the 
latter. 

The  metacarpal  saw  (Fig.  148)  is  a  very  useful  instrument  for  dividing  the 
bone  in  resection  of  joints.  Where  sufficient  retraction  of  the  soft  parts  can  be 
secured,  either  the  broad  or  the  frame  saw  (Figs.  82  and  83)  is  advantageously 
employed.  The  chain  saw  (Fig.  145)  is  not  often  used  on  account  of  the 
difficulty  of  carrying  it  around  the  joint  extremities.  In  very  young  children 
the  soft  bone  may  be  cut  with  a  stout  knife.  It  is  sometimes  an  advantage  to 
grasp  the  end  of  the  bone  about  to  be  sawed  off  by  means  of  the  lion-jaw 
forceps  of  Ferguson  (Fig.  161). 

The  extent  of  the  removal  of  bone  will  depend  on  the  conditions  present. 


374  OPERATIONS    ON    INDIVIDUAL    STRUCTURES 

In  typic  resection  enough  is  removed  to  take  away  the  joint  cartilages.  The 
extent  of  the  resection  also  differs  in  different  Iwnes  (see  Regional  Surgery). 

In  the  case  of  the  knee-joint  a  rigid  though  straight  liml)  is  aimed  at.  In 
the  upper  extremity  a  mobile  connection  in  the  joint  is  desirable.  In  the  first 
instance,  therefore,  the  simple  sawing  through  of  the  line  of  fusion,  or  near  the 
same,  is  sufficient.  In  osteotomy  for  the  correction  of  contracture  and  anky- 
losis the  bone  is  sawed  or  divided  by  the  chisel  two-thirds  through  and  the 
remainder  fractured.  In  the  case  of  the  elbow-joint,  either  the  fused  portions 
are  at  first  separated  and  then  isolated  and  removed,  or  the  ankylosed  portion  is 
removed  in  a  wedge-shaped  piece. 

Resection  of  Joints  for  Tuberculous  Synovitis  and  Myelitis. — In  civil 
practice  joint  resection  is  more  freciuently  required  for  tuberculous  affections 
than  for  traumatism.  Here  the  resection  must  include  the  capsule,  which 
is  always  diseased,  as  a  routine  measure.  In  fact,  under  these  circumstances 
the  operation  becomes  a  typic  extirpation  of  the  entire  diseased  joint ;  this 
includes  the  removal  of  the  entire  synovialis,  the  sawing  off  of  the  joint  ends 
and  the  articular  cartilages,  and  the  apphcation  of  the  sharp  spoon  to  any 
suspicious  point  in  the  cancellous  or  medullary  structure.  In  order  to  gain 
free  access  to  the  parts,  large  transverse  incisions  are  made.  In  some  localities 
it  may  become  necessary  to  divide  tendons  in  making  these  incisions,  in  which 
case  these  must  be  sutured  at  the  close  of  the  operation,  in  order  to  preserve 
their  functions.  In  granulating  myelitis  the  periosteum  is  not  always  involved ; 
even  considerable  of  the  cortical  lamella  may  be  preserved,  in  which  case  the 
operation  is  completed  by  evidement  (see  page  369) .  Hemorrhage  from  the  can- 
cellous or  medullary  tissue  is  sometimes  troublesome.  In  rare  instances  it  may 
become  necessary  to  apply  the  thermocautery  for  its  arrest.  Drainage  of  the 
medullary  cavity,  if  deemed  necessary,  is  secured  by  carrying  a  drain  from  the 
latter  and  either  leading  it  through  the  external  wound,  or  chiseling  an  opening 
in  the  cortical  layer  at  a  convenient  point  and  thence  through  a  separate 
incision  in  the  soft  parts.  The  employment  of  drainage  is  not  always  necessary, 
particularly  if  suppurative  processes  have  not  invaded  the  tuberculous  affection. 

If  the  operation  has  been  thoroughly  done,  the  prognosis  is  generally 
favorable,  provided  the  patient  is  free  from  general  infection.  Recurrence  may 
take  place  after  the  healing  has  been  completed,  or  the  wound  surfaces  them- 
selves may  become  infected.  The  latter  condition  is  known  by  a  yellowish- 
brown  and  flabby  appearance  of  the  granulations  lining  the  cavity  and 
fistulous  passages.  As  soon  as  these  symptoms  are  observed,  immediate 
steps  should  be  taken  to  correct  them.  The  sharp  spoon  or  thermocautery  is 
to  be  applied  and  the  fistulous  tracts  opened  up  freely,  if  necessary  to  gain 
access  to  the  infected  granulations.  These  should  be  thoroughly  curetted  and 
the  sinus  injected  with  pure  carbolic  acid,  followed  at  the  end  of  a  minute  with 
95  per  cent  alcohol.  If  the  curetting  has  been  thoroughly  done  and  further 
packing  of  the  sinus  omitted,  prompt  healing  follows  in  many  cases. 

The  After-treatment  of  Resection  Wounds. — The  parts  are  to  be 
enveloped  in  copious  dressings  of  aseptic  gauze.  If  drainage  has  been  employed, 
these  should  be  specially  thick  in  the  neighborhood  where  the  tubes  emerge. 
The  large  and  dense  dressings,  reinforced  by  thin  basswood  or  pasteboard 
splints,  which  should  extend  beyond  the  next  adjacent  joint  and  be  secured  in 
position  by  starched  gauze  (crinoline)  bandages,  first  wetted  and  then  applied, 


OrKRATIOXS    ON    JOINTS 


375 


Avill  secure  suflicient  immoljilization  of  the  parts  for  the  first  few  weeks  at  least, 
without  the  aid  of  plaster-of- Paris.  I'he  ordinary  rules  governing  redressing 
should  1)0  followed  (see  page  57). 

If  all  goes  well  a  large  resection  wound  may  heal  by  primary  union,  except, 
in  cases  in  which  drainage  is  employed,  the  ]ioints  where  the  drains  emerge. 
Even  in  the  knee-joint  no  more  time  is  occupied  in  uncomplicated  cases  than 
is  necessary  for  recovery  from  a  fracture. 

As  the  wound  approaches  complete  healing,  the  surgeon's  chief  efforts 
should  be  directed  toward  securing  the  desired  functional  result.  In  the 
lower  extremity  solid  union  is  to  be  obtained,  and  \\\\\\  this  in  view  a  fixed 
form  of  dressing,  such  as  will  permit  the  application  of  aseptic  measures  and 
at  the  same  time  completely  immobilize  the  parts,  is  to  be  applied.  The 
bracketed  splint  (Fig.  162),  employed  in  connection  with  a  plaster-of-Paris 
bandage,  serves  the  purpose  admirably. 

In  the  case  of  the  upper  extremity,  if  a  subcapsular  and  subperiosteal 
resection  has  been  possible,  not  much  difficulty  will  be  experienced  in  obtaining 
an  artificial  joint  (nearthrosis).  The  new  bone  is  molded  into  shape  and  even 
articular  extremities  may  form.  Passive  motion  in  the  normal  range  of  the  limb 
will  assist  in  the  molding  process.    The  synovial  membrane  resumes  its  function. 


Fig.   162. — Bracketed  Plaster-of-Paris  Splixt  for  Use  after  Resection  of  the  Kxee-joint. 


In  due  time  active  movements  supplement  those  of  a  passive  character. 
Atrophy  of  the  muscles  resulting  from  nonuse  is  to  be  treated  first  by  the 
galvanic  current,  and  subsequently  by  faradization. 

When  it  is  found  impossible  to  preserve  the  synovial  capsule  and  periosteum, 
an  artificial  joint  may  still  be  secured.  The  perisynovial  connective  tissue 
seems  to  assume  the  function  of  the  synovial  membrane.  Aseptic  healing 
materially  aids  in  producing  a  nearthrosis,  even  where  no  passive  movements 
are  made.  But  flail-like  joints  may  result  from  excessive  mobility,  the 
joint  permitting  movements  in  all  directions  like  a  flail.  This  condition  may 
arise  from  injury  to  unportant  muscles  by  the  incisions,  defective  preservation 
of  the  periosteum,  severe  and  prolonged  suppuration,  the  removal  of  too  much 
bone  and  excessive  passive  movements  during  the  after-treatment,  and  in- 
sufficient stimulation  of  the  muscular  apparatus,  paralysis  of  the  latter  from 
nerve  injury,  and  paresis  of  the  same  from  want  of  use. 

In  the  case  of  the  elbow-joint  a  flail-like  joint  is  of  not  infrec|uent  occurrence 
after  resection  for  tuljerculous  disease.  Under  these  circumstances  it  is 
recommended  to  attempt  to  secure  bony  ankylosis  in  a  proper  position 
(Billroth). 


376  OPERATIONS    ON    INDIVIDUAL    STRUCTURES 

Solid  or  ankylotic  union  must  be  secured  at  the  knee  and  ankle;  and 
even  at  the  hip  it  is  not  a  great  disadvantage.  Good  functional  results  have 
been  obtained,  however,  with  an  artificial  hip-joint.  Whether  solid  union  is 
intended  or  not,  in  case  of  its  occurrence  the  limb  is  to  be  placed  in  a  position 
most  convenient  for  use,  i.  e.,  the  elbow  at  a  right  angle  and  the  knee  in  the 
extended  position. 

During  the  period  of  childhood  every  effort  should  be  made  to  preserve  the 
epiphysial  cartilages  in  resection  of  the  joints.  Injury  of  these  structures,  with 
the  enforced  rest  necessary  in  resection,  leads  to  lessened  longitudinal  growth 
of  the  bone  and  consequent  relative  shortening  of  the  liml). 

Operations  for  the  Removal  of  Joint  Tumors. — Movable  or  free  bodies 
in  the  joints  (page  162)  are  now  generally  removed  by  means  of  incision  of 
the  joint  (arthrotomy).  This  operation,  in  preaseptic  times  an  exceedingly 
dangerous  one,  is  now  performed  aseptically  with  the  best  results.  The 
methods  formerly  in  vogue,  e.  g.,  the  subcutaneous  opening  of  the  capsule  and 
the  forcing  of  the  body  out  of  the  joint  into  the  perisynovial  connective  tissue, 
from  which  point,  after  the  wound  in  the  capsule  was  healed,  it  was  removed 
by  open  incision,  the  pinning  of  its  free  border  to  cause  its  adhesion,  etc., 
are  no  longer  necessary,  provided  a  rigid  enforcement  of  aseptic  principles 
accompanies  open  incision  and  immediate  extraction. 

Difficulty  is  sometimes  experienced  in  locating  the  movable  body.  If  the 
symptoms  are  sufficiently  urgent,  exploration  of  the  joint  is  indicated,  or  even 
resection  may  be  resorted  to. 

Sarcoma,  having  its  origin  in  the  medullary  structure,  is  the  most  impor- 
tant form  of  tumor  of  joints.  While  amputation  above  the  joint  has  been 
resorted  to,  the  operation  of  choice  is  disarticulation  at  the  joint  next  nearest 
the  body.  Recurrences  are  not  uncommon  even  then.  Resection  is  absolutely 
excluded.  Sarcoma  of  the  synovial  membrane  is  very  rare.  It  tends  to 
recurrence,  as  sarcomas  elsewhere,  and  reciuires  the  same  radical  treatment  as 
that  springing  from  the  bone  itself.  Lipomatous  and  large  papillary  pro- 
liferations of  the  synovialis  are  benign  growths  and  do  not  necessarily  demand 
interference.  Extirpation  of  the  growths  is  indicated,  however,  if  their  pres- 
ence gives  rise  to  functional  disturbance. 

AMPUTATIONS  AND  DISARTICULATIONS 

Amputation  and  disarticulation  differ  from  each  other  in  the  method  of 
separation  of  the  bones.  The  first  has  been  termed  amputation  in  conti- 
nuity, the  latter  amputation  in  contiguity.  Both  are  employed  to  follow 
the  same  general  indications. 

Indications. — Conservative  surgery  has -very  greatly  restricted  the  indi- 
cations for  amputation  and  disarticulation.  The  following  formal  statement 
of  these  can  therefore  have  but  a  relative  value: 

1.  Cases  of  Injury. — Removal  of  the  extremity  is  indicated  in  the  com- 
plete crushing  of  a  portion  of  the  extremity,  as  in  severe  machinery  accidents, 
shell  explosions,  etc. ;  in  rupture  of  important  vessels  and  injury  of  large  nerve- 
trunks;  in  unsuccessful  ligation  of  artery  or  vein  or  both;  extensive  rupture 
of  tendons  and  muscles,  in  which  the  dangers  attending  the  attempt  to  save 
the  limb  are  very  great  and  the  usefulness  of  the  limb  itself  but  problematic 


AMPUTATIONS    AND    DISARTICULATIONS  377 

at  best.  The  crushing  of  bones  and  joints  alone  does  not  necessarily  indicate 
removal  of  the  limb;  resection  at  joints  and  in  continuity  will  frequently  pre- 
ser^•e  an  extremity  thus  injured.  But  this,  combined  with  extensive  injury  to 
the  muscles,  tendons,  vessels  and  nerves,  such,  for  instance,  as  usually  happens 
-.when  a  railwa}'  car  passes  over  the  limb,  presents  almost  an  absolute  indication 
for  amputation  or  disarticulation.  This  should  be  performed  as  soon  as 
the  patient  rallies  sufficiently  from  the  shock  to  bear  the  anesthetic  (primary 
amputation). 

2.  Acute  Inflammation. — Removal  of  a  limb  may  be  indicated  by  the 
occurrence  of  acute  intiannnatory  processes,  when  these  cannot  Ije  controlled 
by  antiseptic  measures  and  the  septic  conditions  are  such  as  to  threaten  life. 
Again,  when  the  local  inflammatory  processes  are  such  as  to  render  the  extrem- 
ity functionally  useless,  an  indication  exists  for  its  removal. 

3.  Chronic  Inflammation. — Tuberculosis  of  bones  and  joints  furnishes 
b}^  far  the  greatest  number  of  cases  in  this  class.  Removal  of  the  limb  may  be 
necessar}^  to  prevent  general  infection,  or  to  rid  the  patient  of  a  member  practi- 
cally useless,  which  is  weakening  him  and  exposing  him  to  the  unfavorable 
influences  of  intercurrent  or  secondary  affections  (e.  g.,  amyloid  disease  of 
internal  organs).  While  resection  of  joints  offers  a  conservative  method  of 
treatment  in  many  of  these  cases,  those  in  which  tuberculosis  of  the  lungs, 
kidneys,  or  bowels  exists  do  better  with  amputation.  Cases  of  extensive  tuber- 
culous disease  of  the  wrist-joint,  knee-joint,  and  ankle-joint  require  amputa- 
tion rather  more  frec[uently  in  adults  than  in  children,  resection  failing. 

4.  Extensive  destruction  of  tissue  other  than  that  mentioned  as  result- 
ing from  mechanic  disturbances  may  require  removal  of  an  extremity.  In 
this  class  belong  cases  of  gangrenous  inflammation  from  extensive  burns  and 
frost-bite  of  the  third  degree,  as  well  as  senile  gangrene  and  gangrene  from  venous 
stasis.     Further,  hospital  gangrene  and  malignant  edema  are  to  l^e  mentioned. 

5.  Tumors. — Malignant  tumors  of  the  soft  parts,  such  as  sarcomas  of  the 
skin  and  epithehal  carcinomas,  as  well  as  benign  tumors  which  tend  to  ulcerate 
or  involve  new  portions  of  surface,  such  as  elephantiasis,  and  are  not  amena- 
ble to  other  treatment,  require  amputation  or  disarticulation.  Malignant 
tumors  of  bone  demand  removal  of  the  extremity  rather  than  resection. 

Methods  of  Amputation  and  Disarticulation. — Three  methods  of  sep- 
aration of  the  soft  parts  are  employed,  namely,  circular  incisions,  flap  ampu- 
tation, and  oval  amputation.  None  of  the  methods  about  to  be  described  can 
be  said  to  possess  such  decided  advantages  as  to  be  employed  to  the  exclusion  of 
the  others.  The  method  is  to  be  selected  with  a  view  (1)  to  the  anatomic 
peculiarities  of  the  region  involved  in  the  disease  or  injury  ;  (2)  to  the  character 
of  the  tissues,  their  freedom  from  disease  or  the  extent  of  injury  in  which  they 
are  involved.  It  sometimes  happens  that  the  crushed  and  mangled  tissues 
occupy  but  one  side  of  the  limb,  and  a  large  amount  of  healthy  structure  must 
be  sacrificed  if  a  circular  amputation  is  insisted  on.  But  if  the  flaps  are  fash- 
ioned in  unequal  lengths,  or  an  oval  amputation  is  selected,  the  healthy 
structure  may  l^e  preserved. 

Circular  incision  is  the  simplest  of  all  methods  of  amputation.  The  skin 
is  divided  at  one  level,  a  cuff  turned  back,  the  muscles  divided  to  the  bone, 
and  a  cuff  of  periosteum  fashioned  by  peeling  this  from  the  bone.  The  soft  parts 
are  now  retracted  and  the  bone  divided.    In  making  the  circular  incision  the  long 


378 


OPERATIONS    ON    INDIVIDUAL   STRUCTURES 


amputating  knife  is  grasped  by  the  hand  with  its  edge  up.  First  the  knife  and 
forearm  of  the  operator  are  carried  under  the  hmb,  and  then  the  knife  over  the 
hmb  in  the  position  shown  at  "  1 "  (Fig.  163).  The  heel  of  the  blade  is  passed 
well  into  the  soft  parts  of  the  limb  and  the  knife  swept  around,  assuming  the 
different  positions  shown  in  the  figure  (Joseph  D.  Bryant).  Slight 
to-and-fro  sawing  movements  aid  in  the  section. 

In  dissecting  up  the  cuff  of  skin  the  edge  of  the  scalpel  must  be  directed 
away  from  the  skin,  in  order  to  avoid  injury  to  the  vessels  in  this  structure.  A 
short  cut  on  the  posterior  surface  of  the  limb,  made  parallel  to  the  long  axis  of 
the  latter,  facilitates  the  turning  back  of  the  cuff  and  affords  a  favorable  point 
from  which  the  drainage-tubes  emerge.  In  case  of  difficulty  in  turning  back 
the  cuff,  from  the  presence  of  cicatricial  contraction,  a  similar  vertical  incision 
may  be  made  on  the  anterior  surface,  the  circular  incision  thus  being  converted 
into   two   quadrangular  lateral   flaps.     The   circular  method   is   particularly 

applicable  to  the  lower 
third  of  the  leg,  the  lower 
third  of  the  thigh,  and 
the  middle  of  the  fore- 
arm. Where  the  skin 
and  fascia  are  closely  at- 
tached, there  is  no  objec- 
tion to  including  the 
latter  in  the  cuff.  The 
nutrition  of  the  skin  is 
thus  better  secured. 

The  length  of  the  cyl- 
inder or  cuff  of  skin  will 
depend    on   the    size    of 
the   limb.     The    incision 
through  the  skin  should 
be  placed  at  a  distance 
below  the  proposed  divi- 
sion of    the  bone   corre- 
sponding  to    about  one- 
fourth  the  circumference 
of  the  limb  at  that  point.     In  making  this  incision  the  left  hand  of  the  operator 
should  be  placed  above  the  hne  of  section  and  the  skin  drawn  in  an  upward 
direction.     This  compensates  for  the  tendency  of  the  skin  to  retract. 

Flap  Amputation. — Two  methods  are  here  employed.  In  the  first  the 
flaps  are  made  by  incision,  while  in  the  second  they  are  made  by  transfixion. 
While  the  first  has  the  advantage  of  permitting  an  accurate  fashioning  of  the 
flap  as  to  size,  it  has  the  disadvantage  of  producing  a  steplike  shape  to  their 
surfaces,  owing  to  the  varying  degrees  of  retraction  of  the  different  layers  of 
muscular  structures.  The  method  of  transfixion  avoids  this.  The  blade  of  a 
long  amputation  knife  is  passed  through  the  limb  at  the  base  of  the  proposed 
flap,  with  its  edge  directed  toward  the  apex  of  the  latter.  The  knife  hugs  the 
bone  at  first,  and  with  steady  drawing  movements  the  flap  is  formed,  the  edge 
being  gradually  directed  anteriorly  in  the  case  of  the  anterior  flap,  and  poste- 
riorly in  the  case  of  the  posterior  flap.     By  this  method  the  muscles,  l^eing  made 


Fig.  163. — How  to  Carry  the  Knife  Around  the  Limb  in  Am- 
putation (after  Bryant). 


AMPUTATIONS    AM)    DISAUTICULATIONS  379 

tense  in  front  of  the  knife,  are  divided  more  evenl}'.  Care  must  be  exercised 
not  to  make  tlie  flaps  too  long  and  narrow. 

^Examinations  of  old  stumps  show  that  the  muscular  tissues  atrophy  and 
that  finally  the  ends  of  the  bones  are  covered  onty  by  the  integument  and 
fascia.  In  amputation  through  healthy  structures,  therefore,  the  method 
of  skin  flaps  will  suffice,  but  in  amputation  through  infiltrated  or  otherwise 
altered  structures  a  larger  blood-supply  is  assured  to  the  skin  by  including 
the  muscular  and  fascial  structures  in  the  flap. 

The  employment  of  methods  of  unequal  flaps,  as,  for  instance,  in  the  opera- 
tion in  the  loAver  third  of  the  leg,  knoAvn  as  T  e  a  1  e  '  s ,  or  that  of  one  large 
curtain-shaped  flap,  as  in  the  amputation  of  the  thigh  through  the  condyles 
(C  a  r  d  e  n) ,  will  depend  partly  on  the  parts  involved  in  the  operation,  and 
partly  on  the  injury  or  disease  for  wdiich  the  amputation  is  performed. 

Oval  Amputation. — This  method  does  not  possess  a  wide  range  of  applica- 
tion, yet  it  has  some  advantages  in  special  cases.  Where  large  muscular 
masses  are  to  be  divided,  the  individual  groups  are  retracted  in  varying  degrees, 
as  in  other  methods.  In  oval  incision  the  point  of  the  oval  is  placed  anteriorly 
wdiere  the  retraction  is  the  slightest,  while  the  base  is  located  at  the  point  where 
the  retracted  muscular  structures  surround  the  bone  accurately;  a  more  even 
wound  surface  is  thus  produced.  By  this  method  the  cicatrix  can  be  made  to 
assume  a  certain  position,  which  is  sometimes  desirable,  e.  g.,  on  the  dorsum, 
in  amputation  of  the  fingers,  in  order  to  assure  the  preservation  of  the  tactile 
sense  on  the  end  of  the  stump,  as  well  as  at  the  palmar  surface. 

Choice  between  Amputation  and  Disarticulation. — When  the  choice  lies 
between  amputation  and  disarticulation,  the  following  considerations  should 
be  borne  in  mind:  Disarticulation  is  simpler;  it  requires  only  a  knife  for  its 
performance;  it  does  not  open  the  medullar}-  cavity  and  hence  there  is  less  risk 
of  suppurative  osteomyelitis;  there  are  fewer  structures  opened  up,  the  parts 
about  joints  being  comparatively  thin.  On  the  other  hand,  these  operations 
require  greater  anatomic  knowledge  and  technical  skill;  portions  of  the 
synovial  membrane  are  likely  to  be  left  behind  and  become  subsequently 
hiflamed;  in  case  suppuration  takes  place,  necrosis  of  the  articular  cartilages 
is  liable  to  occur;  the  stump  surface  is  ver}'  broad  and  requires  large  skin 
flaps  to  cover  it  in,  which  are  not  easily  obtained  in  the  region  of  joints;  a 
number  of  tendons  are  divided,  and  the  sheaths  of  these  give  ready  access  for 
suppurative  processes  to  reach  the  tissues  above  the  point  of  operation.  In 
addition,  the  field  of  disarticulation  must  necessarily  be  a  restricted  one, 
demanding,  if  placed  arbitrarily  above  amputation  in  the  choice,  the  sacri- 
fice in  man}"  instances  of  healthy  structures. 

While,  therefore,  there  are  some  advantages  in  disarticulation  as  compared 
with  amputation,  the  latter  under  aseptic  conditions  wall,  as  a  rule,  be  the 
preferable  procedure.  Under  certain  circumstances,  such  as  in  Symes's 
amputation  of  the  foot,  the  two  are  combined.  The  sawing  off  of  the 
prominent  portions  of  the  articular  surface  in  knee-joint  disarticulation 
has  also  found  favor. 

General  Rules  for  the  Performance  of  Amputation. — The  incision  in 
the  soft  parts  should  be  made  in  healthy  tissue,  when  possible.  When  tissues 
are  devitalized  by  the  presence  of  acute  injuries,  cicatricial  conditions  or  edema, 
care  must  be  exercised  that  the  slightest  possible  traumatism  is  inflicted  during 


380  OPERATIONS    OX    INDIVIDUAL    STRUCTURES 

the  operation.  If  suppuration  is  already  present,  vigorous  antiseptic  measures 
must  be  instituted. 

The  separation  of  the  muscles  is  to  be  effected  by  long  and  decided  strokes 
of  the  amputating  knife.  The  intermuscular  connecti^'e-tissue  sj^aces  must  not 
be  opened  up  more  than  is  necessary. 

Before  the  bone  is  sawed  through  a  cylinder  of  periosteum  must  be  peeled 
off  from  the  part  to  be  removed  and  pushed  back  with  the  soft  parts  of  the 
stump.  In  some  localities,  as,  for  instance,  the  lower  third  of  the  tibia,  and 
the  femur,  the  deeper  muscles  and  the  periosteum  are  together  detached 
from  the  bone  with  advantage. 

Careful  retraction  of  the  soft  parts  by  means  of  a  broad  bandage  or  the 
fingers  of  an  assistant,  whenever  practicable,  is  necessary  in  order  to  avoid 
injury  of  these  by  the  saw. 

Splintering  the  bone,  when  the  saw  is  nearly  through,  is  to  be  carefully 
avoided  by  proper  support  of  the  part  to  be  removed.  Likewise,  pinching 
the  saw  is  to  be  guarded  against  (see  page  363). 

When  two  bones  are  to  be  sawed  through,  both  may  be  sawed  simultane- 
ously until  the  larger  of  the  two  is  divided  about  one-third  of  the  way 
through;  section  of  the  smaller  one  is  then  to  be  completed,  final  division  of 
the  larger  one  following.  The  somewhat  roughened  point  which  marks  the 
site  of  the  completion  of  the  work  of  the  saw  is  rounded  off  with  a  rongeur 
(Fig.  90,  A). 

Hemostasis  in  Amputation  and  Disarticulation. — Exsanguination  is  to 
be  accomplished  preliminarily  by  elevation  of  the  limb,  and  the  application  of 
a  roller  bandage  or  of  Esmarch's  rubber  bandage.  Compression,  either  by 
the  fingers  or  by  means  of  a  Pet  it's  tourniquet  or  the  rubber  bandage,  secures 
against  active  hemorrhage  during  the  operation  (see  pages  336  and  338).  The 
separation  of  the  extremity  being  accomplished,  the  larger  vessels  are  secured  by 
hemostatic  forceps  (see  page  340)  before  the  tourniquet  or  constricting  band  is 
removed;  the  latter  is  then  temporarily  relaxed  and  the  smaller  vessels 
secured.  Catgut  is  to  be  employed  for  ligatures.  Parenchymatous  oozing  is 
to  be  arrested  by  means  of  a  large  compress  or  towel  wrung  out  of  hot 
sterilized  water. 

In  cases  in  which  the  vessels  are  the  seat  of  atheromatous  changes,  floss 
silk  (B  a  1 1  a  n  c  e  and  Edmund  s)  may  be  applied;  portions  of  the  sur- 
rounding soft  parts  may  be  included  by  a  circumsuture  (see  page  341). 
Vessels  lying  closely  on  the  bone,  as  well  as  those  difficult  to  grasp  from  any 
reason,  may  also  be  dealt  with  by  the  circumsuture. 

Drainage,  Suture,  and  Dressing  after  Amputation. — When  drainage  is 
employed,  two  or  more  rubber  tube  drains  are  to  be  placed  between  the  sutures. 
These  should  be  sufficiently  long  to  insure"  efficient  drainage  of  the  wound 
surfaces  of  the  stump.  The  tubes  are  secured  from  slipping  inside  the  wound 
cavity  by  a  safety-pin.  Where  septic  conditions  are  already  present,  vigorous 
antiseptic  irrigation  by  means  of  a  1  :  2000  solution  of  mercuric  chlorid  should 
be  employed  and  the  suturing  omitted  altogether.  The  drainage  is  secured 
by  lightly  packing  the  wound  with  gauze  wet  with  a  1  :  2000  solution  of  mer- 
curic chlorid  in  50  per  cent  alcohol  (equal  parts  of  a  1  :  1000  solution  of  mer- 
curic chlorid  and  alcohol). 

The  dressings  are  applied  in  such  a  manner  as  to  make  but  slight  compression 


AMPUTATIONS    AND    DISARTICULATIONS  381 

the  stump.  A  compress  of  heat-sterilized  gauze  should  be  applied  over  the 
line  of  sutures,  ()^'er  this  a  number  of  two-3^ard  square  sterile  gauze  com- 
presses, either  heat-sterilized  or  wrung  out  of  a  1  :  1000  freshly  made  sublimate 
solution,  crum])led  and  evenly  distributed  over  the  parts,  are  placed.  Finally, 
a  covering  of  heat-sterilized  nonabsorbent  cotton  batting,  secured  l^y  roller 
bandages,  completes  the  dressing.  Sliding  of  the  dressings  is  prevented  by 
including  the  next  adjacent  joint  in  the  dressings,  applying  a  light  splint  to 
maintain  this  in  position,  and,  just  before  applying  the  last  turns  of  the  roller, 
passing  a  broad  strip  of  adhesive  plaster  down  the  limb  parallel  to  its  long  axis, 
across  the  face  of  the  stump  and  up  on  the  other  side.  Undue  retraction  of  the 
soft  parts,  which  occasionally  occvirs  in  .amputations  of  the  thigh,  may  be 
prevented  by  preliminary  division  of  the  lower  attachments  of  the  muscles 
(D  a  w  b  a  r  n),  or  by  a  traction  strip  of  plaster,  arranged  stirrup  fashion  and 
attached  to  a  weight  and  pulley  extension. 

The  stump  is  placed  in  an  elevated  position  to  favor  the  return  of  blood 
from  it,  and  steadiecl  by  long  sand  pillows,  placed  on  each  side  to  aid  in  pre- 
venting the  painful  muscular  contractions  which  occur  during  the  first  few 
days. 

Sequels  of  Amputation. — The  sloughing  of  the  flaps  in  cases  of  endar- 
teritis cannot  alwa}'s  be  avoided.  It  is  specially  liable  to  follow  amputation 
for  senile  gangrene.  The  employment  of  insufficient  flaps,  or  their  subsequent 
sloughing  from  any  cause,  notably  the  "buttonholing"  of  these  during  the 
operation,  may  lead  to  conical  stump.  This  may  also  result  from  intermus- 
cular suppuration,  as  well  as  from  contracted  and  elastic  conditions  of  the 
soft  parts,  and  from  growth  of  the  bone  in  young  subjects.  Conical  stump 
may  sometimes  be  prevented,  when  threatened  by  retraction  of  the  soft  parts, 
by  the  application  of  a  broad  strip  of  adhesive  plaster  applied  stirrup  fashion, 
and  weight  and  pulley  extension.  When  due  to  growth  of  bone,  reampu- 
tation  or  subperiosteal  resection  of  the  bone  is  necessary.  This  may  also 
be  required  l)y  extensive  sloughing  of  the  flaps. 

Attachment  of  the  cicatrix  of  the  skin  to  the  sawed  surface  of  the 
bone,  formerly  a  very  annoying  sequel,  is  not  so  frequently  observed  as  it  was 
before  the  aseptic  era.  Eccentric  pains  referable  to  the  fingers  or  toes  of 
the  amputated  member  are  sometimes  very  annoying.  These  gradually  dis- 
appear. Cicatricial  constriction  of  the  nerve  ends  must  be  guarded 
against  by  removing  considerable  portions  of  the  nerve-trunk  and  securing 
rapid  and  aseptic  healing.  The  formation  of  neuromas  is  to  be  guarded 
against  in  the  same  manner.  These  latter  produce  violent  pains  and  require 
excision. 

Finally,  necrosis  of  the  sawed  surfaces  pf  bone  may  occur  later  on,  due 
to  suppurative  periostitis  and  myelitis.  The  sequestra  are  to  be  removed 
from  the  direction  of  the  stump.  It  is  needless  to  say  that,  with  aseptic  and 
antiseptic  methods,  this  is  a  rare  sequel. 

Common  Amputation  Errors. — Sloughing,  or  suppuration,  or  both, 
may  occur  if  the  flaps  are  made  from  tissues  damaged  b}'  injur3\ 

In  malignant  disease,  failure  to  remove  the  parts  well  beyond  the  limits 
of  the  disease  will  result  in  a  return  of  the  disease  in  the  stump. 

In  senile  gangrene  it  will  not  suffice  simply  to  remove  the  gangrenous 
parts.     The  adjoining  tissues,  though  not  actually  invaded,  possess  but  a  slight 


382  OPERATIONS    OX    INDIVIDUAL   STRUCTURES 

degree  of  vital  resistance,  owing  to  either  insufficient  vascular  sup]:»ly  or  trophic 
disturbances  of  nervous  origin,  such  as  perforating  ulcer  of  the  foot,  and  are 
ready  to  break  down  under  the  influence  of  the  disturljanccs  ]jroduced  by  the 
knife. 

In  the  dry  gangrene  present  in  R e y  n a u  d'  s  disease  amputation  of  the 
diseased  fingers  or  toes  is  frequently  followed  by  destruction  of  adjoining 
tissues,  which  may  live  if  left  undisturbed.  Septic  conditions,  however,  are 
rare,  under  these  circumstances.  The  failure  depends  on  the  fact  that  the 
surgeon's  knife  cannot  remove  the  vasomotor  spasm,  on  which  the  gangrene 
depends. 

In  amputation  for  chronic  joint  disease  it  is  an  error  to  make  the  flaps 
from  edematous  tissues,  or  those  riddled  with  sinuses  or  the  site  of  suppurative 
inflammatory  processes.  Under  these  circumstances  the  absence  of  the  neces- 
sary recuperative  power  will  frustrate  the  healing  of  the  amputation  wound. 

Long  disuse  of  a  limb  lessens  the  healing  powders  of  its  tissues.  This  is 
particularly  true  of  limbs  that  have  been  long  confined  in  splints,  tightly 
bandaged,  or  kept  in  an  elevated  position. 

In  selecting  the  site  of  an  amputation,  failure  to  take  into  account  the 
patient's  recuperative  powers  may  result  in  disaster.  Primary  healing  should 
always  be  secured,  if  possible,  in  a  patient  already  greatly  weakened  by  disease 
or  loss  of  blood,  even  if  more  of  the  limb  is  sacrificed  than,  under  other  circum- 
stances, would  seem  to  be  necessary.  At  the  same  time  the  increased  immedi- 
ate risks  of  high  over  low  amputations  should  be  borne  in  mind. 

To  cut  the  flaps  too  short,  and  to  be  compelled  to  adjust  these  forcibly 
over  the  l)one,  is  to  invite  final  exposure  of  the  latter,  either  from  swelling 
and  retraction,  or  from  sloughing.  The  latter  may  likewise  occur  from  rough 
handling  of  the  flaps,  separating  the  muscular  tissues  from  the  skin  portion 
of  the  flaps  w^hile  exposing  the  bone,  or  interfering  unnecessarily  with  the 
blood-supply  at  the  base  of  the  flap. 

In  addition  to  want  of  aseptic  care  in  the  operative  technic  itself,  sup- 
purative inflammatory  processes  may  result  from  injury  to  the  soft  parts 
by  the  teeth  of  the  saw  in  dividing  the  bone;  from  forcing  sawdust  from  the 
bone  into  the  muscular  structures;  from  including  large  masses  of  tissue  in 
the  ligatures;  from  permitting  portions  of  tendons  to  project  from  the  wound 
surfaces;  from  splintering  the  bone  and  leaving  partially  detached  fragments 
behind ;  finally,  from  closing  the  wound  before  the  bleeding  has  been  thoroughly 
arrested  and  from  too  great  tension  on  the  sutures. 

Failure  to  dissect  out  the  main  nerve-trunk  from  a  long  flap  or  to  sever 
it  at  least  an  inch  proximad  to  the  level  of  the  bone,  in  a  circular  amputation, 
may  result  in  painful  stump  from  involvement  of  the  nerve  in  the  cicatrix,  or 
subsequent  regeneration  of  the  divided  nerve  (so-called  stump  neuroma). 


SECTION  XII 
FOREIGN  BODIES 

Foreign  Bodies  and  Their  Effects. — Foreign  bodies  may  become 
lodged  in  certain  parts  without  injury  to  the  tissues,  such,  for  instance,  as  the 
esophagus,  nasal  cavity,  auditory  meatus,  salivary  ducts,  larynx,  trachea, 
vagina,  and  urethra.  These  will  be  considered  in  detail  in  connection  with  the 
diseases  and  injuries  of  these  parts. 

Foreign  bodies  in  the  tissues  enter  through  solutions  of  continuity.  In 
punctured  and  incised  wounds  the  presence  of  a  foreign  body  may  result  from 
the  breaking  off  of  the  instrument  itself,  as,  for  instance,  when  a  knife- 
blade  becomes  imbedded  in  the  skull.  Very  brittle  material  forced  into  the 
tissues,  such  as  glass,  may  also  break  off  and  remain  as  a  foreign  body. 

The  question  of  infection  from  the  foreign  body  is  an  important  one.  In 
case  this  occurs  suppuration  necessarily  follows  and  the  foreign  body  is  loos- 
ened and  cast  off  with  the  pus ;  or  it  may  be  forced  to  the  surface  by  the  granu- 
lations which  follow  the  suppurative  inflammation.  Wooden  splinters  invad- 
ing the  fingers,  on  account  of  their  irregular  surfaces  most  frequently  follow 
this  course  if  not  promptly  removed.  In  cases  in  which  infection  does  not 
occur  the  foreign  body,  by  contact  with  sensitive  nerve  filaments,  produces 
more  or  less  irritation  and  pain  and  requires  removal. 

Bullets  and  other  lead  projectiles  may  be  clean  of  themselves,  but  infection 
occurs  along  their  tracks  from  the  presence  of  other  foreign  bocUes,  bits  of 
clothing,  etc.,  which  have  been  carried  into  the  tissues  with  the  bullet.  It 
is  a  mistake  to  suppose,  however,  that  infected  projectiles  driven  into  the  body 
by  the  explosion  of  gunpowder  cannot  carry  infection  on  their  own  surfaces 
independently  of  that  which  they  receive  from  passing  through  the  clothing 
(La  Garde,  U.  S.  Army).  Though  bullet  wounds  may  be  aseptic,  this 
does  not  result  from  disinfection  of  the  projectile  by  means  of  burning  powder 
or  from  the  passing  of  the  projectile  rapidly  through  the  air,  but  rather  because 
it  was  surgically  clean  beforehand. 

Migration  of  foreign  bodies  may  occur,  as  in  the  case  of  heavy  lead  balls 
in  the  substance  of  the  brain  and  in  the  loose  perimuscular  connective  tissue. 
In  the  first-named  situation  this  migration  is  excessively  dangerous.  Slender 
and  pointed  foreign  bodies,  particularly  needles,  are  sometimes  driven  onward 
by  muscular  contractions  until  they  migrate  to  parts  far  distant  from  the  point 
at  which  they  entered.  Serious  consequences  may  follow  their  passage  through 
important  parts. 

Solid  products  of  living  tissues  may  act  as  foreign  bodies,  such,  for  instance, 
as  biliary  calculi,  vesical  calculi,  etc.,  which,  by  processes  of  ulceration,  have 
left  the  viscus  in  which  they  originally  formed  and  have  become  imbedded  in 
the  surrounding  tissues,  producing  abscesses  and  fistulous  openings. 

Finally,  the  effects  of  foreign  bodies  will  vary  according  to  the  mechanic, 

383 


384 


FOREIGN    BODIES 


chemic,  or  bacterial  influences  incident  to  their  presence.  They  may  likewise 
form  the  nucleus  of  calculi,  when  surrounded  by  physiologic  secretions  from 
which  salts  may  be  deposited  (vesical  and  salivary  calculi). 

Diagnosis  of  Foreign  Bodies.— When  foreign  bodies  are  superficially 
placed,  their  presence  may  be  determined  by  the  elevation  of  the  overlying 
tissues.  When  they  are  situated  in  deep  cavities  or  wounds,  reflected  light  may 
be  employed  for  diagnostic  purposes.  In  the  case  of  foreign  bodies  which  arrest 
the  Rontgen  ray  the  presence  of   these  may  be  determined  by  the  shadow 

which  they  cast  on  the 
fluorescent  screen;  the 
portion  of  the  body  in 
which  the  foreign  body 
is  believed  to  have 
lodged  is  placed  be- 
tween the  vacuum  tube 
of  the  x-ray  apparatus 
and  the  examiner.  For 
purposes  of  permanent 
record  the  sensitized 
plate  is  employed  in 
place  of  the  fluorescent 
screen.  This  is  after- 
ward developed,  as  in 
ordinary  photography. 
In  employing  palpation 
care  should  be  taken  to 
avoid  pushing  the  for- 
eign body  still  further 
into  the  tissues  or  other 
point  of  lodgment. 
When  satisfactory  evi- 
dence is  not  obtained 
by  means  of  the  finger, 
which  is  always  to  be 
preferred  when  avail- 
able, instruments  called 
probes  are  to  be  called 
into  requisition.  The 
wound  may  be  enlarged 
to  permit  the  passage 
of  the  finger.  In  cases 
in  w^hich  the  foreign  body  has  been  driven  into  the  tissues  with  great  force,  as, 
for  instance,  a  bullet,  palpation  may  reveal  th.e  missile  lodged  at  some  distant 
point.  In  cases  in  which  the  bullet  has  followed  the  contour  of  the  bony 
thoracic  wall  a  line  of  tenderness  may  indicate  its  path. 

Probes. — These  are  employed  for  diagnostic  purposes,  l^oth  in  searching 
for  foreign  bodies  in  the  tissues,  and  in  cavities  as  well  (e.  g.,  the  bladder,  etc.), 
and  for  determining  the  condition  of  bone  at  the  bottom  of  suppurative  fistulas 
■connected  with  the  osseous  structure,  as  well  as  that  of  the  w^alls  of  natural 


Fig.  164. — Telephone  Probe. 
A,  Receiver;  B,  flexible  metal  band  for  attaching  receiver  to  the 
operator's  head ;  C,  flexible  conducting  cords ;  D,  electrode  to  be 
placed  in  the  mouth  or  rectum;  E,  screw  connection  for  attaching 
probe;  F,  insulated  portion  of  probe;  G,  noninsulated  portion  of 
probe. 


Ri:.MO\'AL     UF    FORKIGX    BODIES  385 

canals  (<\  (/.,  lacrimal  canal,  esophagus,  urethra,  etc.).  Bougies  or  .sounds 
for  special  purposes  will  be  tlescribetl  in  their  appropriate  places. 

In  acklition,  specially  constructed  probes  are  used  to  follow  sinuous  tracks 
(vertebrated  probe  of  Squire),  and  instruments  of  greater  or  lesser  length  with 
plain  (not  enameled)  porcelain  tip  (Xelaton)  for  the  exploration  of  gunshot 
wountls.  In  the  case  of  the  latter  the  porcelain  tip  receives  and  retains  the 
lead  marking  made  b}-  contact  with  the  bullet.  In  this  connection  is  also  to 
be  mentioned  the  telephone  probe  (G  i  r  d  n  e  r)  for  the  detection  of  metallic 
foreign  bodies  in  the  tissues  (Fig.  164).  In  using  this  instrument  the  alumi- 
num bulb,  D,  is  placed  in  the  patient's  mouth  or  rectum,  the  receiver,  a,  is  held 
to  the  operator's  ear,  while  the  probe,  fg,  is  passed  into  the  wound  in  search 
of  the  bullet  or  other  metaUic  foreign  Iwd}-.  When  the  latter  is  touched,  a 
peculiar  grating  or  clicking  sound  is  heard  in  the  receiver.  If  the  canal  leading 
to  the  foreign  body  is  tortuous  and  the  probe  cannot  be  made  to  follow  this, 
a  long  steel  needle  is  substituted  for  the  probe  and  search  made  by  passing  this 
directly  to  the  suspected  locality.  The  probe  or  needle  used  for  exploring 
should  be  insulated  except  at  the  tip,  in  order  that  the  examiner  may  not  be 
misled  as  to  the  depth  at  which  the  respon.se  to  metalHc  contact  is  given. 

Probes  should  be  made  of  either  virgin  silver,  copper,  aluminum,  or  other 
flexil)le  material,  in  order  that  they  may  be  fashioned  to  follow  the  course  of 
the  fistulous  track  or  wound.     They  are  sometimes  used  as  a  guide  in  makino- 


1^ 


Fig.   16.5.— Elliot's  Uterixe  Repositor  Adapted  as  a  Guide  ix  M.uiixG  Couxter-opexixgs. 

counter-openings.  The  uterine  repositor  of  Elliot  (Fig.  165)  has  been 
adapted  to  this  latter  purpose  (H  u  e  t  e  r)  hy  introducing  it  wliile  straight 
and  curvmg  it  in  the  required  direction  by  turning  the  milled  screw-head  at'ter 
it  has  reached  the  termination  of  the  fistulous  track  to  be  opened. 

The  employment  of  probing  as  a  means  of  diagnosis  is  frequently  very 
unsatisfactor\-.  The  extremity  of  the  probe  can  distmguish  only  a  sohd  foreign 
body  from  the  soft  and  yielding  tissues.  In  the  case  of  soft  foreign  bodies  which 
are  lodged  in  fibrous  or  othei-wise  unyielding  structures  it  is  quite  useless. 
TMien  a  hard  foreign  body  is  lodged  in  unyielding  tissue,  e.  g.,a  splinter  of  glass 
lying  against  a  phalanx,  or  a  soft  foreign  body  lies  in  yieldmg  tissues,  such 
as  ,a  bit  of  clothmg  in  muscular  structures,  the  difficulties  are  ahnost  insur- 
mountable. The  only  trustworthy  form  of  probe  yet  devised  is  that  em- 
ployed for  the  detection  of  metallic  foreign  bodies  (see  telephone  probe). 
Next  to  this  is  the  porcelain-tipped  probe  of  Xelaton  {vide  supra). 

Remo\'al  of  Foreign  Bodies.— When  accessible,  foreign  bodies  should 

be  removed  at  once,  in  order  to  escape  possible  septic  infection.     TMien  deeplv 

placed,  their  removal  is  not  always  an  urgent  necessity.     The  damage  done  by 

extensive  exploratory  procedures  should  be  balanced  against  the  possibly  shght 

harm  which  may  result  from  their  contmued  presence  in  the  tissues.     Life  may 

be  threatened  to  such  a  degree  as  to  demand  that  an  attempt  at  extraction  be 
26 


386  FOREIGX    BODIES 

made.  In  furtherance  of  this,  trephining,  tracheotomy  and  laryngotomy,  cys- 
totomy, urethrotomy,  or  gastrotomy  may  be  indicated  in  individual  cases. 

In  case  a  foreign  body  is  lodged  in  the  skin  or  muscles,  the  ordinary  dressing 
forceps  or  the  dissecting  forceps  are  usually  sufficient  for  its  removal. 
When  convex  surfaces  of  a  foreign  body  present  themselves,  the  forceps  will 
slip,  however,  and  even  tend  to  drive  it  stiU  more  deeply  into  the  tissues. 
This  is  particularly  true  when  the  foreign  body  is  lying  in  a  canal  or  cavity 
such  as  the  urethra  or  nasal  cavity.  Under  these  circumstances  a  fenestrated 
spoon-shaped  instrument,  or  a  curet  of  proper  size,  is  to  be  preferred.  This  is 
to  be  passed  behind  the  foreign  body  and  the  latter  scooped  out.  as  it  were.  In 
the  class  of  instruments  which  operate  b}'  being  first  passed  behind  the  foreign 
body  belong  G  r  a  e  f  e  '  s  coin  extractor  (Fig.  366)  and  the  umbrella  probang 
of  S  a  y  r  e  (Figs.  368  and  369).  (The  removal  of  foreign  bodies  from  special 
parts  will  be  considered  in  Regional  Surgery.)  The  removal  of  small  and 
superficialh'  placed  iron  splinters  from  the  globe  of  the  eye  has  been  accom- 
plished by  means  of  a  powerful  magnet  (Hirschberg). 

Firearm  Projectiles. — ^These  are  either  cylindric,  cylindroconic,  elliptic, 
or  acorn-shaped.  The  shape,  however,  after  the  discharge  of  the  arm 
and  entrance  of  the  ball  into  the  tissues,  changes  according  to  the  density  of 
the  latter  and  to  some  extent  according  to  the  character  of  the  rifling  of  the  bore 
of  the  firearm. 

Where  but  one  opening  exists,  the  ball  is,  as  a  rule,  retained  in  the  tissues. 
Exceptions  to  this,  however,  are  to  be  noted  in  cases  where  the  ball  enters  the 
csLvitj  of  the  mouth  or  is  swallowed,  or  enters  a  viscus,  as  the  stomach,  and  is 
vomited,  or  the  intestinal  canal  or  esophagus  and  finds  its  way  extemall}^ 
through  nomial  channels.  Again,  a  portion  of  clothing  may  be  driven  ahead 
of  the  ball  in  the  case  of  a  partially  spent  ball,  and,  not  perforating  the  clothing, 
be  removed  from  the  wound  of  entrance  by  efforts  made  in  undressing  the 
patient.  A  careful  examination  of  the  clothing  will  eliminate  the  possibility 
of  being  misled  by  this.  The  passage  of  a  ball  by  the  same  force  along  a 
natural  canal  after  it  is  driven  into  the  tissues  is  of  rare  occurrence.  The 
existence  of  two  openings  denotes  the  occurrence  of  a  complete  perforation, 
as  a  rule,  and  the  escape  of  the  projectile,  provided  the  occurrence  of  two 
shots  or  the  existence  of  the  fragment  of  a  divided  projectile  can  be  excluded. 

The  wounds  of  entrance  and  exit  differ  from  each  other  in  most  instances. 
The  former  is  somewhat  larger,  more  rounded  and  blackened  and  contused, 
as  well  as  inverted.  The  latter  is  smaller,  more  oblong,  and  resembles  a  cleft 
with  rather  clean-cut  and  everted  edges.  Instances  occur,  however,  in  which 
these  appearances  cannot  be  relied  on. 

Recent  gunshot  wounds  should  be  examined  at  once  on  account  of  the 
absence  of  swelling  and  sensibility.  The  strictest  antiseptic  precautions  should 
be  obser\'ed,  whether  the  finger  or  the  probe  is  employed.  If  hemorrhage  is  to 
be  feared  from  the  proximit}'  of  large  vessels  to  the  track  of  the  bullet,  the 
exploration  may  be  omitted  entirely  until  proper  preparations  have  been 
made  for  its  removal. 

The  advisability  of  making  an  attempt  at  removal  of  the  bullet  will  depend 
on(l)  whether  or  not  it  can  be  positively  located;  (2)  the  character  of  the 
tissues  in  which  it  has  lodged.  In  case  it  cannot  be  discovered  by  the  finger  or 
probe,  or  the  x-ray,  it  will  usually  be  good  surgery  to  permit  it   to  remain 


FIREARM    PROJECTILES 


387 


undisturbed.  The  occiuTence  of  jihleginonous  inflammation  in  case  septic  mate- 
rial has  been  carried  along  with  the  liall  will  disclose  its  presence.  If  none  such 
occurs,  in  the  great  majority  of  cases  no  harm  will  result  from  its  retention. 
Exceptions  to  this  are  to  ])e  noted,  however,  in  cases  in  which  grave  functional 
disturbances  occur  from  the  presence  of  the  missile  in  the  brain,  bladder,  large 
joint  cavities,  etc. 


Fig.  166. — Tiemann's  Bullet  Forceps. 

The  removal  is  accomplished  by  instruments  specially  designed  for  the 
purpose.  The  most  practicable  of  these  are  the  Tiemann  bullet  forceps 
(Fig.  166).    The  instrument  shown  in  Fig.  167  likewise  serves  a  useful  purpose. 

In  case  no  other  foreign  bodies,  such  as  bits  of  clothing,  etc.,  are  carried 
into  the  tissues  the  wound  will  pursue,  as  a  rule,  an  aseptic  course.  It  is  not 
possible,  however,  to  determine  this  positiveh',  and  it  will  therefore  be  best  to 


Fig.   167. — ^Bullet  Forceps  with  Spoon-shaped  Jatvs. 


drain  the  track  of  the  l^ullet  as  a  routine  method  of  treatment  and  to  adopt  the 
most  stringent  antiseptic  measures  in  the  after-treatment.  The  treatment  ma}' 
therefore  be  summed  up  as  follows:  (1)  removal  of  the  infected  foreign  bodies; 
(2)  cleansing  of  the  accessible  portion  of  the  bullet-track;  (3)  drainage;  (4) 
under  certain  circumstances  dilatation  or  incision  of  the  buUet-track,  and 
counter-openings  for  through-and-through  drainage. 


SECTION  XIII 
BANDAGING 

Materials. — Bandages  are  made  of  various  materials  according  to  the 
uses  to  which  they  are  put.  Bleached  and  unbleached  muslin,  linen,  crinoline, 
Liverpool  cloth,  gauze  and  cheese-cloth,  flannel,  rubber,  and  various  other 
materials  are  used. 

Uses. — Bandages  are  used  to  retain  dressings,  as  in  case  of  wounds;  to 
retain  splints,  as  in  fractures  and  dislocations ;  to  make  pressure,  as  in  the  pal- 
liative treatment  of  varicose  veins  and  also  in  the  treatment  of  tuberculous 
joints  (Bier's  method) ;  to  immobilize  the  parts,  as  in  fractures,  in  which 
case  plaster-of-Paris,  paraffin,  glass,  starch  or  some  other  agent  that  quickly 
hardens  is  worked  into  the  bandage;   to  arrest  hemorrhage. 

Classification. — Bandages  are  divided  as  follows:  (1)  the  simple  or 
roller  bandage,  which  maybe  a  single  or  a  double  roller;  (2)  compound  ban- 
dages, which  are  also  known  as  many-tailed  bandages,  and  slings;  (3)  immobi- 
lizing bandages,  commonly 
made  of  crinoline  or  other 
large  meshed  material  into 
which  plaster-of-Paris  or 
starch  has  been  incorpor- 
ated. The  form  of  ban- 
dage most  frequently  used 
is  the  roller  bandage, 
which  may  be  made  of  any 
of  the  materials  above 
mentioned. 

Strips  of  the  selected 
material  are  cut,  varying 
in  width  and  length  according  to  the  locality  to  be  bandaged.  These  strips 
are  rolled  up  into  a  cylinder  and  constitute  the  roller  bandage.  This  rolling 
may  be  done  by  hand  or  by  means  of  a  special  machine  devised  for  the  pur- 
pose. If  by  hand,  there  are  certain  rules  .which,  if  adhered  to,  make  the  task 
an  easy  one.  One  end  of  the  strip  is  first  folded  on  itself  a  number  of  times 
until  a  small  cylinder  is  formed.  This  cylinder  is  grasped  by  the  right  hand, 
the  forefinger  on  one  end,  the  thumb  on  the  other,  and  while  so  held,  revolved 
by  the  fingers  of  the  other  hand  so  as  to  roll  around  it  the  rest  of  the  strip, 
which  is  guided  by  the  left  hand  (Fig.  168).  A  simpler  method  and  one 
which  must  be  used  if  the  width  of  the  strip  does  not  permit  of  its  being 
grasped  by  the  forefinger  and  thumb,  is  to  start  the  cylinder  as  before,  but 
instead  of  grasping  it  by  the  forefinger  and  thumb,  to  place  it  on  the  anterior 
surface  of  the  thigh  and  roll  toward  the  knee,  tension   being  made  on   the 

388 


Fig.  168. — Rolling  Bandage  by  Hand. 


GENERAL    RULES 


389 


Fig.  169. — Hand  Rollek-bandage  Machine. 


strip  at  the  same  time  and  care  taken  that  each  revolution  of  the  latter  accu- 
rately overlies  the  preceding  one.     If  a  machine  is  used,  one  end  of   the  ban- 
dage is  fastened  by  tension  to  the  revolving  spindle  of  the  machine,  and  this, 
l)oing  turned  by  a  crank,  rapidly 
rolls  up  the  strip.     The  proj^el- 
ling  force  of  these  machines  may 
be  the   hand  (Fig.   169),  or  the 
foot  (Fig.  170).     Also  a  machine 
may  be  so  constructed  as  to  roll 
a  cylinder  the  width  of  the  bolt 
of   material,   which    ma}-  subse- 
quently  be    cut    into    as    many 
roller  bandages  as  desired. 

For  purposes  of  facilitating 
the  description  of  the  applica- 
tion of  a  roller  bandage,  the 
roller  is  divided  into  two  parts. 
Thus,  the  free  end  is  known  as 
the  initial  extremity,  the  in- 
closed end  as  the  terminal  extremity,  while  all  that  portion  between  these 
two  points  is  called  the  body  of  the  bandage.  There  are  also  the  external  and 
internal  surfaces.     The  double  roller,  less  frequently  used  now  than  formerlv, 

is  made  by  sewing  together  the 
initial  extremities  of  two  single 
rollers.  Compound  bandages  and 
immobilizing  bandages  will  be 
treated  of  later. 

Dimensions. — The  width  and 
length  of  a  bandage  vnH  vary  ac- 
cording to  the  part  to  which  it  is 
applied  and  also  accorcUng  to  the 
purpose  for  which  it  is  used.  In 
bandaging  the  fingers  and  toes,  the 
inch-wide  roller  is  to  be  -preferred. 
In  length  tliis  bandage  varies  from 
three  to  five  yards,  according  to 
the  variety  to  be  used.  The  most 
useful  bandages  for  the  head  and 
for  the  extremities  in  cliildren  are 
two  inches  -^nde  and  from  four  to 
seven  yards  long.  Bandages  two 
and  a  half  to  three  inches  wide  and 
six  to  ten  yards  long  are  used  for 
bandaging  the  extremities  in  adults 
and  for  thigh  and  groin  bandages. 
In  bandaging  the  trunk  a  roller 
four  to  six  inches  wide  and  six  to  eight  yards  long  is  most  frequently  used. 
General  Rules. — There  are  a  few  simple  ndes  to  be  observed,  the 
application  of  which  in  applying  iDandages  will  aid  the  beginner  to  master  the  art 


Fig.  170. — Foot  Roli.er-b.\xd.\ge  M.^chixe. 


390 


BANDAGING 


Fig.   171. — Bandage  Scissors. 


more  quickly.  First,  as  to  holding  the  bandage:  It  is  best  to  grasp  the  roller 
tightly  between  the  thumb  and  the  finger,  and  to  rest  it  in  the  hollow  of  the  hand 
so  that  it  will  unroll  easily.  The  internal  surface  of  the  roller  bandage  is  the  one 
that  is  external  when  it  is  applied  to  the  part,  and  the  external  surface  becomes 
internal.  Second,  in  apphdng  a  bandage  to  an  extremity,  always  cause  the 
bandage  when  applied  anteriorly  to  run  away  from  the  median  line  of  the  body. 
This  should  be  borne  in  mind  in  reading  descriptions  of  methods  of  bandaging. 
The  turns  should  always  be  applied  smoothly  and  with  even  pressure.  In  case 
of  an  extremity  the  roller  should  be  applied  from  the  toes  or  fingers,  as  the  case 
may  be,  in  an  upward  direction.     Third,  see  that  the  part  is  in  the  position  it 

is  to  retain  after  the  bandage  is 
applied,  otherwise  there  may  re- 
sult pressure  effects  from  the  sub- 
secjuently  altered  position.  If 
l^leached  muslin  bandages  are 
wrung  out  of  warm  water,  this 
will  be  found  to  facilitate  their 
application.  This  rule  is  par- 
ticularly useful  in  bandaging  fingers.  Fourth,  in  fastening  a  bandage  use 
safety-pins  or  needle  and  thread,  not  plain  pins;  or  tear  the  end  longitudinally, 
knot  to  prevent  tearing,  encircle  the  part  in  opposite  direction  with  the  torn 
ends,  and  tie.  Fifth,  in  removing  bandages  either  cut  or  unwind  them.  If 
the  bandage  is  to  be  cut,  there  are  special  scissors  made  for  this  purpose. 
These  have  a  blunt  point  on  one  blade  of  the  scissors  which  prevents  the 
blade  from  injuring  the  patient  while  they  are  being  used  (Fig.  171).  If  a 
bandage  is  to  be  unwound,  the  unrolled  portion  should  be  loosely  collected  in 
the  hand  in  a  mass  as  the  unwinding  proceeds  and  the  mass  passed  from  one 
hand  to  the  other,  a  rapid  and  neat 
removal  of  the  bandage  being  thus 
effected.  The  removal  of  the  plaster- 
of-Paris  bandage  will  be  discussed 
further  on. 

Varieties  of  Roller  Bandages. 
— In  roller  bandages  a  number  of 
"turns"  are  used.  It  is  quite  neces- 
sary to  understand  the  nature  of 
these  turns  before  using  them  in  any 
special  bandage.  Circular,  spica,  and 
spiral  turns   are   used,  together  with 

several  other  varieties,  and  the  bandage  is  known  as  a  circular,  a  spica,  or  a 
spiral  bandage,  according  to  the  kind  of  turn  employed. 

Circular  Bandages. — A  circular  bandage  is  made  up  of  a  number  of  circular 
turns,  each  turn  accurately  overling  the  turn  preceding  it  (Fig.  172).  This 
bandage  may  be  used  to  retain  dressings  on  small  wounds  of  circular  portions 
of  the  body,  as  the  head,  upper  arm,  and  neck,  and  for  purposes  of  coaptation. 
Oblique  Bandages. — An  oblique  bandage  is  one  in  which  the  turn  runs 
obliquely  around  a  part  without  overlapping  (Fig.  173).  It  is  useful  in  apply- 
ing temporary  dressings. 

Spiral  Bandages. — In  a  spiral  bandage  the  turns  surround  the  part  in  a 


Fig.  172. — Circular  Bandage. 


VAlilKTlKS    Ol"    JiULLKK    BANDAGES 


391 


spiral  manner,  each  turn  covering  in  one-half  or  more  of  the  preceding  turn. 
This  form  of  bandage  can  be  used  on  parts  of  the  body  which  do  not  increase 
rai)idly  in  circumference,  as  the  finger,  chest,  and  abdomen. 

Reversed  Spiral  Bandages  (Fig.  174). — When  the  part  of  the  body  to  be 
bandaged  increases  rajiidly  in  circumference,  as  in  the  case  of  the  forearm  of  a 
well-nourished  person,  it  is  impracticable  to  continue  the  use  of  spiral  turns, 
since  they  soon  assume 
the  shape  of  a  simple 
oblique  bandage  and  be- 
come easily  disarranged ; 
what  is  more  import- 
ant, they  do  not  exert 
even  pressure.  To  over- 
come this  when  a  mus- 
lin bandage  is  used,  the  Fig.  173.— Oblique 
bandage    is    folded    ob- 

lic^uely  on  itself,  or  reversed,  in  such  a  manner  as  to  cause  it  to  conform  to  the 
shape  of  the  part.  In  making  these  reverses  the  forefinger  of  the  left  hand  is 
placed  on  the  previously  applied  turns  to  hold  them  in  place  and  the  head  of 
the  roller  is  turned  toward  the  operator  in  such  a  manner  that  the  slack  of 
the  bandage  is  turned  or  folded  obliquely  on  itself,  the  part  being  thus  fitted 


ANIJAGE. 


^^BMk^y'              ^T"                  ^^H^^^^ 

/  ^ 

V 

Fig.  174. — The  Reversed  Spiral  Ban'dage. 


snugly  (Fig.  174).  As  many  of  these  reverses  are  applied  as  required,  care 
being  taken  that  the  points  of  the  reverses  are  in  alignment  and  that  they  are 
smoothly  applied;  also  that  they  do  not  lie  over  bony  prominences,  as  the 
crest  of  the  tibia,  for  here  they  may  give  rise  to  pressure  effects.  When  a 
bandage  is  made  of  yielding  material,  the  reverse  may  be  made  by  simply 
changing  the  direction  of    the  bandage  in  an    alternating   manner  so  as  to 


392 


BANDAGING 


form  a  short  figure-of-8.  For  instance,  in  bandaging  the  leg,  instead  of 
permitting  the  turns  to  pass  at  right  angles  to  the  limb,  the  turns  are  placed 
obliquely,  the  direction  of  the  obliquity  alternating  at  each  turn.  As  the 
bandage  passes  in  front  of  the  limb  it  is  directed  obliquely  upward;  after 
it  passes  to  the  back  of  the  limb  and  as  it  approaches  the  front  from  the  other 
side,  it  is  directed  obliquely  downward  (Fig.  175). 

Spica  Bandages. — Spica  turns  are  those  which  cross  each  other  in  the  form 
of  the  capital  Greek  letter  "lambda,"  thus  A,  and  a  bandage  made  up  for  the 
most  part  of  these  turns  is  called  a  spica  bandage.  They  are  useful  in  retaining 
dressings  on  the  shoulder    Fig.  211)  and  groin  (Fig.  224)  and  also  in  exerting 

firm  pressure. 

Figure- of -8  Bandages.  —  These 
bandages  are  made  up  of  figure-of-8 
turns,  and  are  most  frequently  em- 
ployed in  the  neighborhood  of  joints. 
A  turn  is  first  taken  above  the  joint, 
and  then  another  below  it,  a  figure  8 
being  thus  formed.  The  joints  over 
which  such  turns  are  used  are  the 
ell^ow,  wrist,  knee,  and  ankle  (Figs. 
216,  217,  229,  230). 

Recurrent  Bandages. — Recurrent 
bandages  are  made  up  of  turns  which 
extend  back  and  forth  over  a  part 
until  it  is  covered,  these  recurrent 
turns  being  secured  by  spiral  turns. 
The  bandage  is  used  to  cover  in  the 
ends  of  fingers  or  toes,  and  in  the 
dressing  of  stumps  (Fig.  176). 

Pressure  Bandages. —  In  cases 
where  pressure  is  indicated,  as  in  vari- 
cose conditions  of  the  extremities,  the 
treatment  of  tuberculous  joints  by 
blood  stasis,  to  control  effusions  in 
joints  and  in  the  soft  parts,  and  to 
control  hemorrhage,  the  pressure  ex- 
erted by  the  muslin  roller  is  insuffi- 
cient unless  applied  so  tightly  as  to 
produce  serious  injury  to  the  soft 
parts.  For  these  purposes  a  bandage  is  needed  which  will  combine  elasticity 
with  strength.  Again,  the  amount  of  elasticity  depends  on  the  condition  for 
which  the  bandage  is  employed.  Bandages  of  stockinet,  flannel,  and  rubber 
will  be  found  to  meet  all  the  various  indications.  The  flannel  bandage  is 
made  and  applied  in  the  same  manner  as  other  roller  bandages.  It  is  useful 
in  preventing  and  limiting  the  progress  of  effusions  and  also  as  a  primary 
roller  under  the  plaster  bandage.  In  babies,  and  persons  of  irritable  skin, 
so-called  canton  flannel  may  be  employed.  Stockinet  and  Japanese  crepe  are 
expensive  but  extremely  useful  materials  of  which  bandages  for  the  treat- 
ment of  varicose  conditions  may  be  made.     They  exert  the  needful  amount  of 


-^ 

Fig.  175. — Spiral.  Bandage  with  Alternat- 
ing Obliquely  Directed  Turns  (Short 
Figure-of-8). 

The  dotted  lines  represent  the  direction  taken  by 
the  next  turn  of  the  bandage. 


VARIKTIKS    OF    ROLLER    UAXDAGES 


393 


uniform  pressuri'  niul  do  not  irritate  the  skin.  The  thickness,  length,  and 
width  of  the  rubber  bandage  vary  with  the  purpose  for  which  it  is  employed. 
For  simple  pressure  in  cases  of  varicose  veins,  a  thin  bandage  is  used.  For 
rendering  an  extremity  bloodless  (E  s  m  arch)  a  thicker  one  is  required. 
When  the  latter  is  not  at  hand,  two  thin  rubber  l^andages  rolled  together 
answer  the  purpose.  When  employed  to  render  a  part  bloodless,  the  rubber 
bandage  is  started  at  the  distal  end  of  the  extremity  and  ascends  with  firm 
pressure  in  spiral  turns.  Each  turn  meets,  but  does  not  overlap,  the  pre- 
ceding turn  (Fig.  12-1).  When  a  level  has  l^een  reached  well  beyond  the  site 
of  the  proposed  operation,  a  few  circular  turns  are  made.  These  circular  turns 
are  lifted  up  over  the  course  of  the  main  artery  by  the  fingers  of  the  left 
hand,  while  the  fingers  of  the  right  hand  thrust  what  remains  of  the  body  of 
the  bandage  vertically  under  these  circular  turns,  and  so  effectually  shut  off 
all  lilood-supply.  The  spiral  turns  are  now  un- 
wound and  this  part  of  the  bandage  placed  loosely 
around  the  extremity  at  the  level  of  the  circular 
turns  (Figs.  125  and  126).  Care  is  taken  not  to 
place  the  circular  turns  at  a  point  where  they  will 
cause  serious  pressure  on  important  nerves.  It 
is  of  extreme  importance  that  no  bandage  of  this 
kind  be  used  in  cases  in  which  there  is  danger  of 
pressing  either  tumor  or  septic  products  into  the 
circulation.  In  such  cases  the  bandage  must  be 
placed  above  the  limits  of  the  disease.  The  rubber 
tourniquet  is  a  narrow,  thick  band  having  a  chain 
attached  to  one  end  and  hooks  to  the  other,  by 
which  it  may  be  secured;  it  is  sometimes  used  to 
secure  the  tourniquet  effect  in  place  of  the  final 
circular  turns.  Tourniquets  are  also  used  for  the 
immediate  control  of  hemorrhage  in  accidents  to 
the  extremities. 

The  chief  use  of  the  rubber  bandage  is  in 
the  treatment  of  varicosities  of  the  lower  ex- 
tremity. It  is  applied  with  even  pressure,  begin- 
ning at  the  base  of  the  toes,  and  in  case  of  vari- 
cosity of  the  leg  ending  just  below^  the  knee. 
Should    the    varicosity  also    be    present    on    the 

thigh,  the  bandage  is  continued  upward  to  the  groin.  Reversed  turns  are 
not  necessary,  as  the  elasticity  of  the  bandage  allows  it  to  conform  to  the 
shape  of  the  extremity.  It  is  fastened  by  means  of  two  tapes  attached  to 
its  distal  end.  These  tapes  are  wound  around  the  extremity  and  tied. 
While  not  a  strictly  curative  measure,  it  relieves  those  cases  for  which  it  is 
indicated.  The  daily  contact  of  the  rubber  will  produce  eczematous  condi- 
tions in  some  individuals.  To  avoid  this  a  thin  flannel  bandage  is  applied 
next  the  skin.  The  bandages  should  be  removed  at  night  when  the  patient 
has  resumed  the  recuml^ent  position,  and  reapplied  in  the  morning  before  he 
arises.  After  removal  they  should  be  rinsed  in  lukewarm  water  and  hung  up 
in  folds  to  dry. 

For  use  in  the  Bier  treatment  of  tuberculous  joints  a  much  shorter  ban- 


FiG.  176. 


Recurrent  Bandage 
OF  Stump. 


394 


BANDAGING 


dage  can  be  employed.  Half  a  dozen  circular  turns  are  all  that  are  necessary.  As 
this  method  is  employed  in  children,  whose  skin  is  particularly  prone  to  irrita- 
tion, and  as  the  rubber  is  to  be  kept  applied  for  several  hours  at  a  time,  it  is  well 
to  protect  the  skin  by  the  application  of  a  few  turns  of  a  canton  flannel  bandage. 
The  amount  of  compression  necessary  to  produce  venous  stasis  must  be  judged 
by  the  effect  on  the  limb.     A  bluish  "marbled"  appearance  is  to  be  produced. 

The  arterial  blood-supply  is  not 
to  be  arrested.  The  parts  below 
the  diseased  area  are  to  be  sup- 
ported by  a  snugly  applied  roller 
bandage  (Fig.  209). 

Permanent  Fixation  Ban= 
dages. — The  ordinary  roller  ban- 
dage, while  it  fixes  the  parts  at 
the  time  it  is  applied,  soon  be- 
comes loosened  if  the  parts  are 
moved.  In  cases  which  require 
absolute  rest,  therefore,  we  are 
obliged  to  incorporate  into  the 
bandage  some  material  which  will 
make  it  stiff,  so  as  to  secure  im- 
mobilization of  the  parts  and  dur- 
ability of  the  bandage.  The  uses 
of  such  bandages  are  manifold. 
They  frequently  take  the  place  of 
ordinary  splints.  For  purposes  of 
stiffening,  soluble  glass,  paraffin, 
starch,  and  plaster-of-Paris  are 
most  frequently  employed.  The 
starch  bandage  is  made  by  soak- 
ing large  meshed  material  in  a 
strong  solution  of  starch,  then 
spreading  it  flat  to  dry.  Ban- 
dages of  various  widths  are  made 
of  thin  material.  When  ready 
for  use,  the  starch  bandage  is 
(lipped  in  hot  water  for  a  few 
minutes  or  sufficiently  long  to 
allow  the  water  to  penetrate  the 
innermost  parts  of  the  bandage. 
It  is  wrung  out  almost  dry  and 
apphed  as  any  other  bandage. 
It  soon  dries,  forming  a  firm 
protective  splint,  but  it  is  neither  so  hard  nor  so  durable  as  the  plaster-of- 
Paris  roller.  It  has  the  advantage,  however,  of  being  much  lighter,  and  is 
therefore  to  be  preferred  in  simple  injuries  of  the  upper  extremity  which  require 
fixation,  but  the  patient  should  be  instructed  to  take  special  precautions 
against  further  injury.  It  may  be  removed  by  cutting  with  a  knife,  or  with 
scissors  if  only  a  few  layers  have  been  used,  or  by  unrolling. 


Fig.  177. — Plastek  Roller-bandage  Machine. 


PERMANF.XT    FIXATION    BANDAGES  395 

Method  of  Preparation  of  Plaster-of-Paris  Bandage. — An  opcn-meshed 
niatiuial,  such  as  "cross  barred"  crinohne,  is  selected  lor  the  bandage.  This 
is  cut  the  proper  width  and  length,  and  rolled.  This  rolling  may  be  done  by- 
hand  or  in  any  one  of  the  numerous  bandage  boxes  made  for  the  purpose. 
As  the  bandage  is  being  rolled,  fine  plaster-of-Paris  (dental  plaster)  is  rubljed  in 
if  the  operation  is  carried  on  by  hand;  or  allowed  to  fall  in  the  turns  of  the 
bandage  if  a  special  machine  is  used  (Fig.  177).  When  a  bandage  of  the 
required  length  and  width  has  thus  been  prepared,  a  small  rubber  elastic  is 
snapped  around  it  to  keep  it  from  unrolling,  and  it  is  wrapped  in  oiled  paper  or 
placed  in  an  air-tight  can  to  prevent  the  plaster  from  becoming  moist  and  cak- 
ing, which  it  is  quite  likely  to  do  unless  kept  in  a  dry  place.  Made  in  this  way, 
these  plaster  bandages  may  be  kept  indefinitely.  Should  they  become  damp 
at  any  time,  they  may  be  put  in  an  oven  and  dried. 

When  they  are  required  for  use,  the  oiled  paper  is  removed  from  a  sufficient 
number  of  bandages  of  the  proper  width.  These  are  placed  on  a  table  with  a  basin 
containing  hot  water.  Table  salt,  in  the  proportion  of  one  heaping  teaspoonful 
to  two  quarts,  added  to  the  water  is  useful  in  hastening  the  hardening,  but 
causes  brittleness  of  the  plaster  cast  after  setting.  Zinc  oxid  added  to  the  water 
is  also  useful  in  facilitating  the  setting.  The  member  to  which  the  plaster  is 
to  be  applied  is  to  be  thoroughly  cleaned  and  shaved.  It  is  now  covered  with  a 
thickness  of  sheet  wadding,  applied  as  a  roller  bandage.  Extra  layers  of  cotton 
are  placed  over  bony  prominences,  such  as  the  olecranon,  patella,  and  crest  of 
the  tibia.  This  is  to  prevent  local  gangrene  of  the  skin  overlying  these  points, 
from  excessive  pressure.  In  place  of  sheet  wadding  a  thick  canton  flannel  roller 
may  be  used.  Whatever  is  used,  its  purpose  is  to  transmit  the  pressure  of  the 
plaster  equally,  and  to  prevent  direct  pressure  on  the  skin.  Care  must  be  taken 
not  to  cover  the  bony  prominences  with  too  much  cotton  in  the  endeavor  to  pro- 
tect them,  lest  the  purpose  of  the  fixation  bandage  be  nullified  by  allowing  the 
parts  to  move  inside  it.  Sometimes  a  plaster-of-Paris  bandage  is  applied, 
allowed  to  harden,  and  then  cut  along  each  side  and  removed.  It  is  then 
padded  with  cotton  and  reapplied  as  a  removable  plaster-of-Paris  splint. 
In  such  cases  sheet  wadding  or  a  canton  flannel  roller  is  not  to  be  applied 
primarily,  as  an  exact  cast  of  the  parts  themselves  is  desired.  To  protect  the 
skin  from  irritation  and  to  facilitate  the  removal  of  the  cast,  vaselin  is  thickly 
coated  over  the  entire  surface  which  is  to  come  in  contact  with  the  plaster. 

When  the  skin  and  bony  prominences  are  protected,  two  of  the  bandages  are 
placed  in  the  basin  of  hot  water.  These  are  left  immersed  until  the  water  has 
penetrated  to  the  core.  The  surplus  water  is  expelled  by  squeezing  the  bandage 
by  pressure  on  its  sides.  In  order  to  save  time,  as  one  is  taken  from  the 
basin  another  is  placed  therein  until  the  required  number  is  reached.  The 
general  rules  which  govern  the  application  of  other  bandages  apply  also  to  the 
plaster  roller.  It  is  applied  evenly,  smoothly,  and  with  uniform  pressure. 
Those  parts  which  are  subjected  to  the  most  strain,  as  the  elbow,  knee,  ankle, 
and  other  joints,  are  reinforced  by  supplementary^  turns  of  the  roller.  The 
number  of  layers  applied  depends  on  the  purpose  for  which  the  bandage  is 
emplo3'ed.  Simply  to  retain  a  dressing  in  place,  two  or  three  layers  are  all  that 
are  necessary.  On  the  other  hand,  six  to  eight  layers  are  necessary  to  insure 
immobility  of  joints.  In  the  ambulatory  treatment  of  fractures  of  the  lower 
extremity  (see  page  136)  more  layers  will  be  required  than  in  case  the  patient 


396 


BANDAGING 


is  to  rest  quietly  in  bed.  If  the  bandage  is  used  over  a  wound,  as  in  compound 
fracture,  a  window  or  a  fenestra  may  be  cut  through  the  entire  thickness  of  the 
bandage.  Should  very  large  fenestrae  be  required,  pieces  of  soft  iron  may  be 
bent  into  the  shape  of  the  Greek  letter  i2  and  used  to  reinforce  the  bandage. 
These  fenestrae  should  be  cut  after  the  plaster  has  hardened,  so  as  not  to  impair 
its  strength.  In  order  to  produce  a  nice  finish,  the  last  plaster  roller  applied 
may  have  a  selvage.  This  is  so  applied  as  to  cover  the  raw  edge  at  each  suc- 
cessive turn  and  leave  the  selvage  exposed.  Dry  plaster  may  be  nibbed  in  after 
the  bandage  is  complete.  The  parts  must  be  kept  perfectly  quiet  in  the  re- 
quired position  all  through  the  application  of  the  bandage  and  long  enough 
aftenvard  to  allow  the  wet  plaster  to  harden. 

Removal  of  the  Bandage. — In  the  case  of  the  extremities,  the  line  where 
the  bandage  is  to  he  cut  should  be  on  the  external  surface,  but  many  circum- 
stances will  govern  this  point,  so  that  no  hard  and  fast  rule  should  be  laid  down. 
There  are  many  appliances  specially  devised  for  the  removal  of  plaster-of-Paris 
splints,  such  as  knives  and  saws  of  different  shapes  (Fig.  178).  A  strong 
straight -bladed  resection  knife  or  a  shoemaker's  knife  answers  the  purpose. 
The  cut  is  to  be  made  obliquely  rather  than  at  right  angles  to  the  surface.     A 


Fig.  178. — Removal  of  Plaster  Splint  with  Plaster  Saw. 


weak  solution  of  acetic  acid  (common  vinegar)  is  painted  along  the  proposed 
line  of  incision.  This  softens  the  plaster  and  makes  it  easier  to  cut.  The 
bandage,  or  cast,  as  it  is  more  commonly  called,  should  l)e  removed  in  one 
piece  to  avoid  any  unnecessary  disturbance  of  the  parts.  \'inegar  may  be 
used  to  remove  any  plaster  which  has  adhered  to  the  hands.  Water,  to  which 
either  granulated  sugar  or  molasses  has  been  added,  is  also  useful  in  removing 
plaster  from  the  hands. 

Dangers  of  the  Plaster-of-Paris  Bandage. — The  dangers  attending  the 
application  of  an  ordinary  bandage  are  multiplied  in  the  case  of  the  plaster-of- 
Paris  bandage.  This  is  specially  true  in  cases  of  recent  fracture  which  have 
been  immoblized  in  this  way.  At  the  first  sign  of  superficial  venous  stasis  the 
bandage  is  cut  completely  open  from  end  to  end;  should  the  blood  stasis  not  be 
relieved  by  this,  the  bandage  must  be  entirely  removed.  All  cases  should  be 
watched  for  the  first  few  days  following  the  application  of  the  bandage.  The 
danger  of  gangrene  is  always  present. 

Compound  Bandages. — These  are  usually  made  of  unbleached  muslin, 
cut  in  various  ways  to  fomi  the  shape  of  the  part  of  the  body  to  which  they  are 
to  be  applied.     There  is  a  great  number  of  these  bandages,  but  few  of  them 


COMPOUND    BANDAGES 


397 


are  reall}^  useful.  Their  true  range  of  usefulness  is  limited  to  the  hurried  first 
dressing  done  on  the  battle-field.  As  a  rule,  they  afford  neither  the  comfort  nor 
the  security  of  the  well-applied  roller  bandage. 

The  sling  is  one  of  the  most  frequentl}'  used  of  the  compound  bandages. 
It  is  made  in  three  ways.  Two  of  these  are  for  the  upper  extremity  and  one  for 
the  lower.  The  former  is  a  single  triangle  of  muslin,  or  a  yard  square  of  muslin 
folded  diagonally  to  form  a  triangle.  The  apex  of  the  triangle  is  applied  under 
the  elbow,  the  half  of  the  triangle  which  is  next  the  body  goes  over  the  opposite 
shoulder,  the  other  half  of  the  triangle  goes  over  the  shoulder  of  the  affected  side. 
The  ends  of  these  two  halves  are  knotted  at  the  back  of  the  neck,  enough 
traction  being  put  on  each  end  to  insure  that  the  body  of  the  triangle  affords 
equal  support  for  the  entire  length  of  the  forearm.  To  afford  additional  secu- 
rity the  two  sides  of  the  sling  may  be  sewed  or  pinned  together,  parallel  to 


Fig.  179. — T-bandage. 


Fig.  180. — Double  T-bandage. 


the  forearm  and  just  above  it.  The  apex  of  the  triangle  is  pinned  to  the  front 
of  the  sling.  The  second  form  for  the  upper  extremity  is  used  as  a  sling 
for  the  upper  arm.  It  is  of  use  only  when  the  patient  is  in  bed.  A  strip 
of  muslin  as  broad  as  the  arm  is  long  and  about  three  feet  in  length  is  used. 
One  end  is  pinned  along  the  median  line  of  a  previously  applied  bandage  of  the 
chest.  The  other  end  is  passed  between  the  body  and  the  arm,  partly  sur- 
rounding the  latter,  and  brought  back  to  the  starting-point,  where  it  is  pinned 
or  sewed  fast.  It  should  be  applied  with  just  enough  tension  to  support  the 
arm  comfortably.  For  the  lower  extremity  a  sling  may  sometimes  be  used 
with  advantage  in  fractures  of  the  femur.  A  long  board  splint,  10  inches 
broad  and  long  enough  to  extend  from  the  axilla  to  below  the  heel,  is  well 
padded  and  secured  to  the  chest  and  pelvis  by  bandages  or  adhesive  plaster. 
One  of  the  long  sides  of  a  broad  strip  of  muslin  is  tacked  to  the  uppermost  edge 
of  that  portion  of  the  splint  corresponding  to  the  leg  and  thigh.     The  body 


398 


BANDAGING 


of  the  strip  is  then  passed  under  the  leg  and  thigh  and  fastened  to  the  first  edge, 
the  whole  thus  forniino;  a  convenient  sling. 

The  single  and  double  T-bandage  are  both  frequently  used,  the  first  to 
hold  perineal  dressings  in  place  in  the  female,  the  second,  in  the  male.  These 
are  called  perineal  T-bandages.  They  are  made  of  a  broad  strip  of  muslin 
sufficiently  long  to  encircle  the  pelvis.  This  is  called  the  body  of  the  bandage. 
To  this  is  attached  a  narrow  strip  at  the  center  of  the  I^ody  of  the  bandage  to 
form  the  single  T  (Fig.  179).  In  case  a  double  T  is  required  (Fig.  180)  two 
strips  are  fastened  a  short  distance  to  each  side  of  the  middle  of  the  body  of 
the  bandage. 

T-bandages  may  be  made  of  varying  breadth  and  length  of  body  and  strips 


Fig.  181. — The  Chest  "T  "-binder. 


SO  as  to  conform  to  different  parts  of  the  body.     Examples  of  this  are  found  in 
the  chest  T,  the  abdominal  binder,  and  the  breast  binder. 

In  applying  the  chest  T,  the  body  of  the  bandage,  10  or  12  inches  broad, 
surrounds  the  chest,  while  the  vertical  straps  pass  from  behind  over  the  shoulder 
and  are  fastened  in  front  (Fig.  181).  The  plaited  abdominal  binder  is  from 
12  to  IS  inches  wide  and  in  length  one  and  one-half  times  the  circumference  of 
the  body.  It  is  securely  pinned  in  front  with  safety-pins  and  made  to  fit  snugly 
by  taking  plaits  on  each  side  (Fig.  182).  Straps  of  muslin  are  passed  from 
behind  forward  over  the  perineum  and  fastened  posteriorly  and  anteriorly  to 
prevent  any  slipping  of  the  bandage.  These  are  called  perineal  straps.  These 
are  both  fastened  with  safety-pins  so  as  to  admit  of  easy  removal  when  soiled. 


COMPOUND    BANDAGES  399 

The  breast  binder  (Fig.  ISo)  is  a  modification  of  tlicT-lKindago  of  the  chest. 


Fig.   182. — The   Plaited  Abdominal  Binder. 


It  consists  of  one  piece  of  doubled  muslin  made  into  an  armless  jacket.     In 


Fig.   183. — The  Breast  Binder. 


400 


BANDAGING 


applying  it,  the  portions  which  correspond  to  the  straps  of  the  T-bandage  are 
fastened  over  each  shoulder  with  safet3^-pins.     The  ends  of  the  body  of  the 


Fig.   184. — The  Triangle  of  the  Groin. 


bandage  are  then  secured  to  each  other  in  front.     A  nice  fit  is  obtained  by  tak- 
ing plaits  wdth  safety-pins  on  each  side. 


I'lG.   185. — Hernia  Bandage. 


Single  and  douljle  T-bandages  may  be  used  to  retain  dressings  on  different 
parts  of  the  head  and  face. 


RETRACTORS 


401 


A  variety  of  T-bandagc  known  as  the  triangle  of  the  groin  is  often  useful. 
The  vertical  strap  of  the  single  T  is  made  broad  and  triangular,  the  base  of  the 
triangle  being  attached  to  the  body  of  the  bandage.  The  portion  of  the  body 
■with  the  triangle  attached  is  placed  over  the  dressing  to  be  retained.  The 
ends  of  the  body  of  the  bandage  are  then  fastened,  while  the  apex  of  the 
triangle  is  drawn  across  the  perineum  to  be  attached  to  the  bodv  behind 
(Fig.  184). 

A  useful  hernia  bandage  is  made  by  lengthening  this  bandage  so 
as  to  encircle  the  body  twice,  attaching  the  initial  extremity  of  a  roller 
3  inches  wide  to  the  apex  of  the  triangle  and  using  this  as  a  spica  for  the  thigh 
and  groin  (Fig.  185). 

The  four-tailed  bandage  is  a  light  and  effective  dressing  for  fracture  of  the 
lower  jaw  with  slight  displacement,  and  is  also  used  to  retain  dressings  in  the 
region  of  the  chin.     A  strip  of  bandage  4  inches  broad  and  3  feet  long  is 


Fig.   1S6. — Four-tailed  Bandage  for  the  Jaw. 


employed.  Each  end  is  split  in  two  and  torn  longitudinally  until  within  4 
inches  of  the  middle  of  the  bandage.  This  four-inch  square  is  called  the  body 
of  the  bandage.  The  center  of  the  body  is  applied  to  the  symphysis  of  the 
jaw^  The  upper  two  of  the  four  tails  are  carried  directly  backward  to 
beneath  the  inion  and  are  there  draw^n  taut  and  knotted.  The  four  loose  ends 
are  then  tied  tightly  together  and  the  superfluous  ends  cut  away  (Fig.  186). 

Retractors. — These  are  bandages  made  by  splitting  strips  of  muslin  six 
or  eight  inches  wide  into  two  or  three  tails,  according  as  they  are  to  be  used  for 
retracting  the  soft  parts  around  one  or  two  bones. 

A  many-tailed  bandage  is  sometimes  used  to  retain  the  dressings  of  an 
abdominal  wound  and  to  exert  even  pressure  as  the  fluid  is  withdrawn  in  para- 
centesis abdominis.  The  body  portion  of  the  bandage  occupies  a  little  more 
than  one-half  of  the  circumference  of  the  abdomen,  the  tail  strips  being  supplied 
by  tearing  or  splitting  the  remainder  from  the  ends.     The  bandage  is  secured 


402 


BANDAGING 


in  position  by  crossing  the  tail  strips,  drawing  upon  them  until  the  bandage 
fits  snugly  and  pinning  the  end  of  each  separately  at  the  sides  (Fig.  187). 

Adhesive  Plaster. — Two  varieties  are  furnished  for  the  use  of  the 
surgeon,  namely,  the  officinal  resin  plaster  and  that  known  as  rubber  plaster 
or  surgeon's  adhesive  plaster. 


Fig.   187. — Many-tailed  Bandage  for  the  Abdomen. 
The  appearance  of  the  bandage  before  appHcation  is  shown  in  the  upper  right-hand  corner  of  the 

illustration. 

Uses. — Adhesive  plaster  is  sometimes  used  to  approximate  the  edges  of 
superficial  wounds,  and  occasionally  the  skin  edges  of  deep  wounds,  when  it  is 
desirable  to  avoid  the  use  of  skin  sutures.     When  used  for  this  purpose,  it  should 


Fig.  188. — The  First  Pieces  of  Dressing  of  an  Abdominal  Section  Held  in  Place  by  Adhesive 

Plaster  and  Tapes. 


be  sterilized  by  passing  the  strip,  cut  ready  for  use,  with  its  back  down  across 
the  flame  of  a  spirit  lamp.  Care  should  be  taken  not  to  apply  the  plaster  too 
hot.  When  resin  plaster  is  used,  it  will  be  necessar}^  to  heat  it  in  order  to  make 
it  adhere.     When  rubber  plaster  is  used  for  purposes  other  than  the  above,  it 


ADHKSIVK    PL  AST  FOR 


403 


will  not  i-ociuire  hcatiiig.     In  uppl3ing  the  plaster  to  the  edge  of  a  wound  a  space 
should  be  left  between  the  strips  for  the  escape  of  discharges. 

It  is  sometimes  necessary  to  secure  dressings  and  bandages  from  slipping 
by  the  use  of  adhesive  plaster.  This  is  most  freciucntly  used  in  this  connection 
for  retaining  the  first  pieces  of  dressing  in  position  in  the  case  of  an  ab- 
dommal  section  (Fig.  188).  When  bandages  are  liable  to  slip,  as,  for  instance, 
m  the  thigh,  a  strip  of  adhesive  plaster  laid  over  the  bandage  on  the  inner 
and  outer  side  is  useful  in  holding  the  bandage  in  place. 


Fig.  189.— Stirrup  of  Adhesive  Plaster  to  Prevent  the  Foot  from  Assuming  the  Equinus 

Position. 
A,  A,  Padded  foot-pieces;    B    B    adhesive  plaster  straps;  C    C   bandages  securing  foot-pieces  in  position; 
D,  D,  bandages  securing  upper  ends  of  adhesive  plaster  straps.  i  uu. 

Adhesive  plaster  is  useful  for  retaining  a  graduated  compress  in  position, 
and  for  exercising  direct  pressure  as  a  local  therapeutic  measure,  as  in  strapping 
a  testicle  and  the  female  breast.  It  is  likewise  employed  to  secure  the  immobili- 
zation of  parts,  as  in  fractures  of  the  ribs  and  sprains  of  joints,  and  to  prevent 
the  foot  from  assuming  the  equinus  position  when  patients  are  long  confined  to 
the  bed  (Fig.  189).  In  the  ambulatory  treatment  of  ulcer  of  the  leg  adhesive 
plaster  is  useful  to  relieve  the  hyperemia  of  the  parts.  Resin  plaster  is  to  be 
preferred  for  this  purpose. 


Fig.  190. — Buck's  Extension. 


One  of  the  most  important  uses  of  adhesive  plaster  is  to  furnish  a  means  of 
making  extension  on  an  extremity  for  the  purpose  of  maintaining  the  frag- 
ments m  position  after  a  fracture.  It  is  most  frequentlv  emploved  for  thts 
purpose  in  fractures  of  the  femur  (G  u  r  d  o  n  B  u  c  k).  The  adhesive  plaster 
IS  cut  so  as  to  provide  both  longitudinally  and  obliquelv  placed  strips  (Fig.  190) 


404 


BANDAGING 


The  parts  to  which  adhesive  plaster  is  to  be  appHecl  should  first  be  cleansed, 
and,  if  hairy,  they  should  be  shaved.  In  removing  rubber  plaster  the  latter 
may  be  loosened  by  the  application  of  alcohol  or  benzin.  The  streaks  of  gum 
left  at  the  site  of  the  edges  of  the  plaster  may  be  removed  by  the  use  of  the  same 
agents.  In  making  a  second  application  of  plaster  care  should  be  taken  to 
avoid,  if  possible,  the  site  of  the  formerly  applied  strips. 

Head  Bandages. — Fronto-occipital  Bandage  (Fig.  191). — Roller  two 
inches  wide,  four  yards  long.  Application:  Fix  the  initial  extremity  of  the 
bandage  beneath  the  inion  with  the  index-finger  of  the  left  hand.  Carry 
the  roller  across  the  parietal  bone  of  the  left  side  to  the  forehead,  around  the 
forehead,  then  over  the  right  parietal  region  to  its  starting-point.  Repeat 
this,  taking  care  that  each  turn  accurately  covers  the  preceding  turn.  Com- 
plete by  fastening  under  the  inion. 

Oblique  Bandage  (Fig.  192). — Roller  two  inches  wide,  four  yards  long. 
Application:    Fix  the  initial  extremity   of  the   bandage  by  means  of   one 


Fig.  191. — Fronto-occipital  Bandage. 


Fig.   192. — Oblique  Bandage. 


or  two  fronto-occipital  turns.  From  the  occiput,  pass  the  roller  obliqueh^  over 
the  first  parietal  eminence  to  the  forehead,  make  a  fronto-occipital  turn,  ending 
at  the  forehead,  pass  oblicjuely  over  the  second  parietal  eminence  to  the  occiput, 
then  make  a  fronto-occipital  turn.  Continue  these  turns  in  the  order  named, 
making  each  oblique  turn  over  the  lower  two-thirds  of  the  preceding  turn. 
Complete  the  bandage  by  a  fronto-occipital  turn. 

Recurrent  Bandage  (Fig.  193). — Roller  two  inches  wide,  seven  vards  long. 
Application  :  ]\Iake  one  or  two  fronto-occipital  turns  to  secure  the  initial 
extremity  of  the  bandage.  Beginning  at  the  central  point  of  the  forehead, 
make  a  reverse  and.  carry  the  roller  directly  backward  in  the  median  line  over 
the  vertex  to  just  below  the  inion;  at  this  place  fold  the  bandage  on  itself  and 


HEAD   BANDAGES 


405 


carry  it  forvv^ard  to  the  left  of  the  first  turn,  so  that  it  overlaps  it  by  two-thirds. 
Rojieat  these  recurrent  turns  between  the  occiput  and  the  forehead  until  the 


Fig.  193. — Recurrent  Bandage,  or  Capeline  of  the  Head. 


Fig.   194. — V-bandage  of  Head  and  Chin. 


Fig.  195. — Barton's  Bandage. 


whole   of  the  left  half  of  the  skullcap  is  covered.     Then  secure  these  by  a 
fronto-occipital  turn. 

Forehead  and  Chin  (Fig.  194). — Roller  two  inches  wide,  seven  yards  long. 


406 


BANDAGING 


Application:  Fix  the  initial  extremity  of  the  bandage  by  one  or  two 
fronto-occipital  turns.  From  below  the  inion  pass  below  the  right  ear  around 
the  side  of  the  jaw  to  the  chin,  across  the  anterior  surface  of  the  chin,  along  the 
left  side  of  the  jaw,  and  below  the  left  ear  to  below  the  inion;  then  make  a 
fronto-occipital  turn.  Alternate  these  fronto-occipital  turns  with  the  oc- 
cipitomental turns.  Instead  of  passing  from  the  occiput  to  the  chin,  the  second 
turn  may  pass  from  the  occiput  to  the  upper  lip,  if  so  indicated.  This  bandage 
is  known  as  the  forehead  and  upper  lip  bandage.  If  the  second  turn  passes 
around  the  neck,  it  is  known  as  the  forehead  and  neck  bandage.  Or,  the 
second  turn  may  cross  any  part  of  the  nose,  and  the  bandage  is  then  called 
forehead  and  nose  bandage. 

Occipitofacial.— Roller  two    inches    wide,    four    yards    long.      Applica- 
tion:    This  bandage  consists  of  two  turns  which  are  identical  with  the  first 


Fig.  196. — Modified  Barton's  Bandage  for  Lower  Jaw. 


two  turns  of  G  i  b  s  o  n  '  s  bandage  {vide  infra).     The  intersections  are  fastened 
by  means  of  safet3^-pins. 

Barton's  Bandage  (Fig.  195).— Roller  two  inches  wide,  seven  yards  long. 
Application:  With  the  index-finger  of  the  left  hand  fix  the  initial  extremity 
of  the  bandage  to  the  vertex  of  the  head  in  the  middle  line.  Pass  down 
over  the  left  parietal  bone  to  the  starting-point.  This  forms  turn  number  1. 
To  form  turn  number  2,  continue  from  the  starting-point  over  the  temporal 
bone  of  the  left  side,  down  the  side  of  the  left  cheek  in  front  of  the  left  ear,  under 
the  chin,  up  the  side  of  the  right  cheek  in  front  of  the  right  ear,  and  over  the 
right  temporal  bone  to  the  starting-point.  To  form  turn  number  3,  continue  from 
the  starting-point  over  the  left  parietal  bone  to  below  the  inion,  below  the  right 
ear  around  the  right  side  of  the  inferior  maxilla  to  the  front  of  the  chin,  passing 
around  the  anterior  aspect  of  the  chin  to  the  left  aspect  of  the  inferior  maxilla, 


II 10  AD  15  AND  AG  KS 


407 


over  this  and  below  the  left  ear  to  just  below  the  inion.  These  three  turns 
repeated  a  number  of  titnos  in  the  order  given  constitute  Barton's  bandage 
proper.  In  the  modified  Barton's  bandage  (Fig.  196),  after  the  third 
turn,  there  is  added  a  fronto-occi})ital  turn.  The  points  of  intersection  of  the 
various  turns  arc  secured  by  means  of  safety-pins. 

Gibson's  Bandage  (Fig.  197).— Roller  2  inches  wide,  7  yards  long. 
Application:  Fix  the  initial  extremity  in  front  of  the  ear,  carry  the  roller 
beneath  the  jaw,  up  on  the  other  side  and  over  the  fronto-parietal  region 
to  the  place  of  beginning.  After  making  three  such  vertical  turns  a  reverse 
is  made  a  little  above  the  ear  and  three  horizontal  turns  are  made  sur- 
rounding the  head.  A  reverse  is  then  made  in  front  at  the  root  of  the  nose 
and  the  bandage  carried  backward  over  the  head  to  the  nucha,  where  it  is 
again  reversed  and  three  or  more  turns  are  made  around  the  front  of  the  chin. 


Fig.  197. — Gibson's  Bandage. 
Safety-pins  should  be  placed  on  all  the  intersections  to  prevent  the  bandage  from  slipping. 

The  points  of  reverse  and  intersection  of  the  bandage  are  secured  with  safety- 
pins.  One  or  two  final  vertical  turns  add  to  the  neatness  of  the  chin  portion 
of  the  bandage. 

Oblique  Bandage  of  Jaw  (Fig.  198).— Roller  two  inches  wide,  seven  yards 
long.  Application :  Fix  the  initial  extremity  by  means  of  one  or  more  fronto- 
occipital  turns.  If  it  is  intended  to  cover  in  the  left  side  of  the  jaw,  the 
bandage  is  passed  from  right  to  left;  if  the  right  side,  from  left  to  right.  From 
the  occiput,  pass  below  the  ear,  under  the  chin,  and  bring  the  bandage  up  over 
the  opposite  angle  of  the  jaw,  thence  carry  it  over  the  side  of  the  face  just 
posterior  to  the  external  angular  process  of  the  frontal  bone  and  in  front  of  the 
ear  of  the  same  side  to  the  vertex.  Carry  the  bandage  across  the  vertex  behind 
the  ear  of  the  opposite  side  to  the  point  at  which  it  first  passed  under  the  chin, 
continue  around  under  the  chin  as  before,  this  time,  however,  placing  the  turn  so 


408  BAXDAGIXG 

as  to  overlap  the  posterior  two-thirds  of  the  previous  turn.    Continue  these  turns, 
each  turn  overlapping  the  posterior  two-thirds  of  the  previous  turn,  until  the 


Fig.  198. — Obliuue  Bandage  of  Angle  of  the  Jaw. 


Fig.  199. — Combined  Head,  Neck,  and  Figure-of-8  of  the  Axilla. 

■  space  between  the  external  angular  process  and  the  ear  is  completely  covered  in ; 
the  oblique  turns  may  include  the  ear,  if  so  indicated.     Then  carry  to  above  the 


HEAD  BANDAGES 


409 


opposite  ear,  reverse,  make  two  or  three  fronto-occipital  turns,  and  fasten. 
The  obhque  turn  may  be  apphecl  on  both  sides,  one  alternating  with  the  other. 
This  l)andao;e  may  be  comliined  with  the  forehead  and  neck  bandage  and  with 
the  figure-of-S  of  the  neck  and  axilla  {vide  infra).  Combined  thus  and  taking 
in  with  its  oblique  tin*ns  both  sides  of  the  head  and  omitting  the  ear,  it  makes 
the  best  bandage  known  for  securing  dressings  after  operation  on  the  neck 
(Fig.  199).  ^ 

Single  Eye  Bandage  (Fig.  200). — Roller  two  inches  wide,  four  yards  long. 
Application:  Fix  the  initial  extremity  by  one  or  two  fronto-occipital 
tui-ns.  If  it  is  desired  to  cover  in  the  left  eye.  the  turns  should  pass  from  right 
to  left;  if  the  right  eye,  vice  versa.  From  the  occiput,  the  roller  pa.sses  below 
the  lobe  of  the  ear  to  the  cheek,  upward  over  the  cheek  to  the  glabella,  thence 
obliquely  over  the  frontal  and  parietal  region  of  the  opposite  side  to  the  occiput. 


Fig.  200. — Single  Eye  Baxdage. 


Fig.  201. — Double  Ete  Baxdage. 


This  forms  turn  number  1.  A  fronto-occipital  turn  is  now  made.  Turn 
number  2  is  identical  with  turn  number  1 .  except  that  it  ascends  and  overlaps 
the  latter  by  one-third  its  width.  It  will  be  found  more  comfortable  for  the 
patient  if  the  second  turn  and  subsecpent  turns  cover  in  the  ear  instead  of 
passing  below  it,  as  in  the  case  of  the  first  turn.  These  turns  are  repeated, 
alternating  with  the  fronto-ocdipital  turns  until  the  eye  is  entirely  covered 
in.  A  few  fronto-occipital  turns  complete  the  bandage.  The  ear  is  pro- 
tected from  pressure  by  cotton. 

Double  Eye  Bandage  (Fig.  201). — Roller  two  inches  wide,  six  yards  long. 
Application:  The  initial  extremity  is  fixed  by  one  or  more  fronto-occipital 
turns.  Then  from  the  occiput  the  roller  passes  imder  the  lobe  of  the 
first  ear  to  the  cheek,  upward  upon  the  cheek  to  the  glabella,  covering  in  the 
first  eye,  and  thence  obliciuely  across  the  opposite  frontal  and  parietal  region 
to  the  occiput.     A  fronto-occipital  turn  is  now  made.     From  the  occiput,  the 


410 


BANDAGING 


roller  now  travels  up  over  the  parietal  and  frontal  regions  to  the  glabella, 
then  over  the  second  eye  obliquely  down  the  cheek  beneath  the  lobe  of  the 


Fig.  202. — Bandage  for  Supporting  Tampons  in  Anterior  Nares. 


Fig.  203. — Figure-of-8  Bandage  of  the  Neck  and  Axilla. 


ear  to  the  occiput.     A  fronto-occipital  turn  is  now  made.     The  turn  covering 
in  the  first  eye  is  now  repeated,  two-thirds  of  the  previous  turn  are  covered  in, 


BANDAGES    OF    THK    TRUNK    AND    EXTREMITIES 


411 


tluMi  a  fi-onto-occipital  turn  is  taken  and  the  turn  covering  in  the  second 
eye  is  rt'pcated,  and  so  on,  each  eye  turn  ascending  by  two-thirds  of  the  width 
of  the  i)receding  turn  and  alternating  with  a  fronto-occipital  turn.  'I'hese 
are  continued  until  the  eyes  are  completely  covered  in. 

Bandages  of  the  Trunk  and  Extremities.— Figure-of-8  of  the  Neck  and 
Axilla  (Fig.  203).— Roller  two  inches  wide,  four  yards  long.  Application: 
Fix  the  initial  extremity  of  the  bandage  by  one  or  two  circular  turns  around 
the  neck,  not  too  tightly  applied.  According  to  the  axilla  to  be  included, 
pass  the  roller  ol^liquely  across  the  corresponding  shoulder  under  the  axilla, 
and  back  again  obliquely  over  the  same  shoulder,  crossing  the  first  oblique 


Fig.  204. — Spiral  Bandage  of  the  Chest. 
F"iRST  Method. 


Fig.  205.^ — Spiral  Bandage  of  the  Chest. 
Second  Method. 


turn.  Now  take  a  circular  turn  around  the  neck.  Alternate  the  circular  neck- 
turns  with  the  turns  passing  under  the  axilla  and  crossing  over  the  shoulder. 
Each  succeeding  turn  overlaps  the  preceding  one  by  two-thirds  its  width.  A 
circular  turn  around  the  neck  completes  the  bandage.  '' 

Spiral  Bandage  of  the  Chest  (Fig.  204).— Roller  three  inches  wide,  eight 
yards  long.  Application  :  The  initial  extremity  of  the  roller  is  fixed  by 
means  of  one  or  two  circular  turns  around  the  chest  at  the  level  of  the  xiphoid 
cartilage.  The  roller  then  gradually  ascends  the  chest  by  means  of  spiral  turns, 
each  turn  covering  in  tv^^o-thirds  of  the  preceding  one,  until  the  level  of  the 
axillary  fold  is  reached.     Here  one  or  two  circular  turns  complete  the  bandage. 


412 


BANDAGING 


Another  way  of  completing  the  bandage  is  to  make  one  circular  turn  at  the 
level  of  the  axillary  folds,  pass  under  the  axilla  to  the  posterior  aspect  of  the 
chest,  thence  obliquely  to  the  opposite  shoulder,  over  this  to  the  anterior  aspect 
of  the  chest  wall  and  diagonally  down  over  the  turns  of  the  bandage  to  the 
xiphoid  cartilage,  where  the  bandage  ends.  This  last  oblique  strip  is  secured 
by  pins  to  each  spiral  turn  of  the  bandage  (Fig.  205).  Or,  the  spiral  turns  may 
be  supported  by  shoulder-straps  pinned  in  front  and  behind  (Fig.  206). 

Anterior  Figure-of-S  of  the  Chest  (Fig.  207).— Roller  three  inches  wide, 
eight  yards  long.  Application  :  Two  or  more  circular  turns  are  first  made 
around  the  chest  at  the  level  of  the  axillary  folds.     From  a  point  commencing 


Fig.  206. — Spiral  Bandage  of  the  Chest.     Third  Method. 

at  the  center  of  the  sternum,  the  roller  is  carried  over  one  shoulder  to 
its  posterior  aspect,  through  the  axilla  of  the  same  side  to  the  anterior 
aspect  of  the  chest,  diagonally  across  the  chest  to  the  other  shoulder,  then 
over  the  other  shoulder  to  its  posterior  aspect,  through  the  axilla  to  the 
anterior  aspect  of  the  chest,  and  diagonally  across  it  to  the  starting- 
point,  thus  forming  a  cross  over  the  sternum.  These  turns  repeated  a 
number  of  times  complete  the  bandage.  Or,  the  circular  turns  may 
alternate  with  the  figure-of-8  turns.  The  turns  may  be  placed  so  that  each 
will  exactly  cover  in  the  preceding  one  or  overlap  it  by  a  portion  of  its 
width.  Finally,  the  bandage  is  secured  by  a  pin  through  the  intersection  of 
the  turns  over  the  sternum. 


JANDAGE^.    OF    THIO    TRUNK    AND    EXTREMITIES 


413 


Fig.  207.— Oblique  Bandage  of  the 


He.ad  and  Anterior  Figure-of-8  of  the  Chest. 


Fig.  208. -Posterior  Figure-of-8  Bandage  of  the  Chest. 


414 


BAXDAGING 


Posterior  Figure-of-8  of  the  Chest  (Fig.  208). — Roller  three  inches  wide, 
eight  yards  long.  Application:  The  initial  extremity  of  the  bandage  is 
fixed  between  the  scapulas  at  the  level  of  the  axilla,  and  the  roller  carried 
over  one  shoulder  to  its  anterior  aspect,  through  the  axilla  of  the  same  side  to  its 
posterior  aspect,  and  thence  to  the  starting-point.  The  roller  is  then  carried 
in  a  similar  manner  around  the  other  shoulder,  and  these  turns  are  alternated 
first  around  one  shoulder  and  then  around  the  other  until  the  roller  is 
finished.  The  bandage  is  pinned  at  the  point  of  intersection  between  the 
scapulas. 

Breast  Bandage  (Fig.  209). — Single  roller  three  inches  wide,  eight  yards 
long.  Application:  Starting  from  the  scapula  of  the  affected  side,  carry 
the  roller  over  the  shoulder  of  the  opposite  side  to  the  anterior  chest  wall, 


Fig.  209. — Bandage  Sling  for  the  Breast. 


Fig.  210. — Double  Breast  Bandage. 


and  thence  under  the  affected  breast  and  obliquely  along  the  lateral  and  pos- 
terior chest  wall  to  its  starting-point.  Repeat  this  turn  in  order  to  secure  the 
initial  extremity.  This  is  turn  number  1 .  Turn  number  2  is  an  oblique  one, 
starting  from  the  initial  extremity  over  the  scapula  of  the  affected  side  and 
going  completely  around  the  body  just  under  the  affected  breast.  These  two 
turns  are  alternated,  each  covering  in  its  corresponding  preceding  turn  by  two- 
thirds  its  width,  thus  gradually  ascending  and  covering  the  breast  completely. 
To  support  both  breasts  the  bandage  is  repeated  on  the  opposite  side  (Fig.  210). 
Ascending  Spica  of  the  Shoulder  (Fig.  211). — Roller  three  inches  wide, 
eight  yards  long.  Application:  Fix  the  initial  extremity  of  the  roller  by 
means  of  one  or  two  circular  turns  around  the  arm  of  the  affected  side  at  the 
level  of  the  axillary  fold,  or  at  a  short  distance  below  it.     Carry  the  bandage 


BANDAGES  OF  THE  TRUNK  AND  EXTREMITIES 


415 


directty  across  the  anterior  aspect  of  the  chest  to  the  axilla  of  the  opposite  side, 
under  the  axilla  to  the  posterior  aspect  of  the  chest,  and  across  this  to  the 
starting-point.  jMake  a  circular  turn  around  the  arm  at  the  starting-point  and 
then  a  second  turn  around  the  chest,  similar  to  the  first,  but  ascending  and 
covering  in  two-thirds  of  the  previous  turn,  except  at  the  opposite  axilla  where 
the  turns  exact l.v  overlap  each  other.  The  chest  turns  are  alternated  with  the 
circular  turns  around  the  arm,  each  chest  turn  ascending  and  covering  the 
preceding  turn  by  one-third  of  its  width.  In  this  manner  the  shoulder  is 
ascended  by  spica  turns  until  it  is  completely  covered.  The  bandage  is  com- 
pleted by  a  circular  turn  around  the  arm  and  there  fastened. 

Descending  Spica  of  the  Shoulder.— Roller  two  and  a  half  inches  wide, 
seven  yards  long.  Application:  Fix  the  initial  extremity  of  the  bandage 
by  means  of  one  or  two  circular  turns  around  the  arm  at  the  level  of  the 


Fig.  211. — Ascending  Shoulder  Spica. 


Fig.  212. — Velpead's  Bandage.     First  Turn. 


axillary  fold  or  at  a  short  distance  below  it.  Carry  the  roller  over  the  shoulder 
and  the  anterior  surface  of  the  chest  as  high  up  as  it  can  be  made  to  go,  thence 
around  the  axilla  of  the  opposite  side,  around  the  posterior  aspect  of  the  chest 
and  over  the  shoulder  to  the  starting-point.  Here  a  circular  turn  is  taken. 
These  turns  are  alternated,  each  chest  turn  descending  by  one-third  the  width  of 
the  preceding  turn  until  the  shoulder  is  completely  covered.  The  bandage 
is  finally  completed  by  a  circular  turn  around  the  arm. 

Velpeau's  Bandage  (Figs.  212,  213,  and  214).— Two  rollers,  three  inches 
wide,  eight  yards  long.  Application:  The  arm  of  the  affected  side  is 
drawn  across  the  chest,  the  palmar  surface  of  the  fingers  resting  on  the  point 


416 


BANDAGING 


of  the  sound  shoulder,  with  a  layer  of  cotton  between.  The  initial  extremity 
of  the  roller  is  placed  over  the  scapula  of  the  unaffected  side,  and  the  roller 
carried  over  the  point  of  the  opposite  shoulder,  thence  down  across  the  outer 
and  then  the  posterior  surface  of  the  arm  of  the  same  side  and  under  the  elbow 
to  the  anterior  chest  wall  to  the  axilla  of  the  unaffected  side  and  thence  to  the 
starting-point,  the  first  turn  being  thus  completed.  This  turn  is  repeated  in 
order  firmly  to  fix  the  initial  extremity  of  the  roller.  After  this  second  turn  is 
completed,  the  roller  is  carried  directly  around  the  body,  passing  over  the  elbow 
of  the  affected  side  near  its  point,  thence  to  the  axilla  of  the  sound  side,  and 
thence  to  the  starting-point  over  the  scapula  of  the  sound  side.  These  turns 
are  alternated,  each  succeeding  turn  overlapping  the  previous  one  by  two-thirds 


Fig.  213. — Velpbau's  Bandage.     Second  Turn. 


Fig.  214. — Velpeau's  Bandage  Completed. 


its  ■v\ddth,  the  shoulder  turns  gradually  approaching  the  base  of  the  neck,  and 
the  turns  crossing  the  elbow  gradually  ascending  to  the  shoulder,  until  the  last 
turn  passes  across  the  wrist  and  is  secured  behind. 

Figure-of-8  of  the  Elbow  (Fig.  216). — Roller  two  inches  wide,  four  yards 
long.  Application:  Place  the  elbow  in  the  position  in  which  it  is  to  remain 
and  pass  two  circular  turns  around  the  flexure  and  tip  of  the  olecranon. 
Circular  turns  are  now  made  alternately  above  and  below  the  joint  until  the 
latter  is  completely  covered,  each  turn  covering  in  two-thirds  of  the  preceding 
one.  Or,  fix  the  initial  extremity  of  the  bandage  by  one  or  more  circular  turns 
a  few  inches  above  the  joint.      Return  obliquely  to  the  starting-point  and 


BANDAGES  OF  THE  TRUNK  AND  EXTREMITIES 


417 


make   a    circular   turn.     Alternately   make   a    circular  turn  above  the  joint 
gradually  approaching  the  tip  of  the  olecranon  from  both  directions;  finally 


Fig.  216. — Figure-of-8  of  the  Elbow. 

complete  by  a  circular  turn  directly  around  the  flexure  and  covering  in  the 
olecranon. 

28 


418 


BANDAGING 


Figure-of-8  of  the  Hand  and  Wrist  (Fig.  217). — Roller,  one,  two,  or  three 


and  a  half  inches  wide,  two  yards  long. 


Fig.  217. — Figure-of-S  of  the  Hand  and  Wrist. 


Application:     Fix  the  initial   end 
of  the  roller   by  one  or  two  cir- 
cular turns  at   the  wrist.     Carry 
it    obliquely    across    the    dorsum 
to  the  base  of  the  index-finger  or 
little    finger,    make    one    circular 
turn,  followed   by  one  half   turn 
around  the  hand  at  the  metacar- 
pophalangeal articulation,  and  re- 
turn to  the  wrist.    After  complet- 
ing a  circular  turn  at  the  wrist, 
again   carry   it   obliquely   to   the 
base  of  the  index  or  little  finger, 
and  proceed  as  before.     The  turns  are  continued,  each  overlapping  the  pre- 
ceding one  by  two-thirds  its  width,  until  the  dorsum  of  the  hand  is  completely 
covered.     A  circular  turn  at   the  wrist  completes  the 
bandage. 

Figure-of-8  of  the  Hand  and  Wrist  (Palmar 
Application). — This  is  applied  in  the  same  manner 
as  the  preceding,  except  that  the  oblique  turns  cross 
the  palm  instead  of  the  dorsum  of  the  hand. 

Reversed  Spiral  of   Upper  Extremity  (Fig.  218). 
— Roller  two  and  a  half  inches  wide,  seven  yards  long. 
Application:     Fix    the    initial  extremity  of    the   ban- 
dage by  means  of    one  or    two  circular   turns  around 
the  wrist;    cross 
the   back  of  the 
hand  obliquely 
to   the    level   of 
the  last   phalan- 
geal joints,  where 
a  circular  turn  is 
made ;    then    by 
means    of    spiral 
or  reversed  spiral 
turns  ascend  the 
hand   to  the  me- 
^        1^^^     tacarpophalan- 
Hj^  H^l     geal   joint  of  the 
^^H^^^l     thumb;  pass  ob- 
mB^^^^     liquely     to     the 
w^  wrist  and  take  a 

circular  turn  at 
this  point;  then 
back  obliquely 
to  take  a  circular 
turn  around  the  body  of  the  hand.  Make  three  or  more  of  these  figures-of-S 
and  finish  bv  a  circular  turn  at  the  wrist.     Ascend  the  forearm  by  means  of 


Fig.  218. — Bandage  for 
Wrist,  Forearm,  and 
Elbow. 


Fig.  219. — Spiral  of  the  Finger. 


BANDAGES  OF  THK  TRUNK  AND   KXTKEMITIES 


419 


spiral  and  reversed  spiral  turns  mil  11  the  elbow  is  reached.  If  it  is  desired 
to  keep  the  arm  flexed,  cover  in  the  elbow  by  a  series  of  figure-of-8  turns 
while  in  flexion;  if,  however,  the  arm  is  to  be  kept  extended,  continue  the 
spiral  and  reversed  turns  over  the  elbow  and  up  the  arm.  The  bandage  is 
completed  by  one  or  two  circular  turns  at  the  level  of  the  axillary  fold.  Care 
should  be  taken  here,  as  elsewhere,  not  to  allow  the  reverses  to  press  over 
bony  prominences,  as,  for  instance,  the  ridge  of  the  ulna;  also  to  keep  the 
reA'erses  in  line. 

Spiral  of  the  Finger  (Figs.  219  and  220). — Roller  three-quarters  of  an 
inch  wide,  three  yards  long.  Application :  The  initial  extremity  of  the  roller 
is  secured  by  two  or  three  turns  around  the  middle  phalangeal  joint. 
The  bandage  is  carried  in  a  spiral 
manner  to  the  base  of  the  finger, 
each  turn  covering  one-half  of 
the  preceding  turn.  A  circular 
turn  is  made  at  the  base  of  the 
finger,  and  the  bandage  carried 
by  means  of  spiral  turns  to  its 
starting-point  at  the  middle  pha- 
langeal joint.  From  the  posterior 
surface  of  the  joint  a  recurrent 
turn  is  now  j^assed  directly  over 
the  tip  of  the  finger  to  the  ante- 
rior surface  of  the  joint.  The  fin- 
gers of  the  operator's  left  hand 
hold  the  extremities  of  this  turn 
taut  and  in  position  while  a 
second  turn  is  passed  back  over 
the  inner  half  of  the  finger-tip  to 
the  starting-point  of  the  first. 
This  is  also  held  in  place  while  a 
third  and  final  turn  is  passed 
over  the  outer  half  of  the  finger- 
tip to  the  anterior  surface  of  the 
joint.  A  circular  turn  secures  the 
ends  of  the  three  loops,  the  ban- 
dage being  then  carried  to  the 
distal  extremity  of  the  finger  by 
means  of  spiral  turns.  At  the  extremity  another  circular  turn  is  taken,  which 
secures  the  parts  of  the  loops  extending  to  the  right  and  left  side  of  the 
finger-tip.  Finally,  by  means  of  spiral  turns  the  base  of  the  finger  is  reached 
and  the  bandage  fastened  either  by  splitting  longitudinally  for  a  distance  of  six 
or  eight  inches,  knotting  the  bandage  to  prevent  further  sphtting,  and  tying 
the  ends  directly  around  the  base  of  the  finger;  or  by  splitting  for  a  distance  of 
ten  or  twelve  inches,  tying  at  the  base  of  the  finger  and  carrying  the  superfluous 
ends  around  the  wrist  once  or  twice  in  opposite  directions,  and  finally  tying. 
This  last  effectually  prevents  the  loosening  and  falling  off  of  the  bandage. 

The  reversed  spiral  of  the  finger  is  applied  in  the  same  manner  as  the 
spiral,  with  the  exception  that  reversed  spiral  turns  take  the  place  of  spiral  turns. 


Fig.    220-— Spiral 


5AXDAGE      OF      FiXGER. 

Method. 


Second 


420 


BANDAGING 


.   \ 

^^^^^H 

1 

i 

i 

'^^^^B 

^. 

Fig.  221. — Spica  of  the  Thumb. 


Spica  of  Thumb  (Fig.  221). — Roller  one  inch  wide,  three  yards  long. 
Application:    Fix  the  initial  extremity  at  the  wrist   by  one  or  two   circular 

turns.     Carry   the    roller 

over  the  dorsal  aspect  to 
the  tip  of  the  thumb  and 
there  make  a  circular 
turn;  then  return  to  the 
wrist  and  make  a  circular 
turn  around  the  wrist. 
The  roller  is  again  carried 
across  the  dorsal  aspect 
of  the  thumb  and  a  sec- 
ond circular  turn  is  made 
around  the  thumb,  this 
last  overlapping  the  first 
in  the  direction  of  the 
base    of    the   thumb    by 

two-thirds  of  its  width.  This  procedure  is  continued  until  the  thumb  is  cov- 
ered. A  turn  around  the  wrist  completes  the  bandage,  W'hich  is  then  fast- 
ened.    Spiral  turns  may  be  used 

around  the  thumb  in  place  of  cir- 
cular ones.    A  few  recurrent  turns 

may  be  first   placed  over  the  tip, 

if  it  is  desirable  to   inclose  it  in 

the  bandage. 

Any  of   the  above   described 

spiral  or  reversed  spiral  bandages 

of  the  finger  may  be  applied  to 

the  thumb. 

Demi-gauntlet  (Dorsal)  (Fig. 

222). — Roller  one  inch  wide,  four 

yards    long.      Application:     Fix 

the     initial     extremity     at     the 

W'rist    by    one    or    two    circular 

turns.    Carry  the  roller  obliciuely 

across  the  back  of  the  hand  to 

the  base  of  the  thumb ;  here  make 

a  circular  turn  and  return  to  the 

wrist.     ^lake   a  circular  turn  at 

the  wrist  and  then  carrj'  the  roller 

obliciuely  across  the  back  of  the 

hand  and  the  base  of  the  index- 
finger,    there   making    a    circular 

turn,  and  return  to  the  wrist.    So 

continue  until  the  base  of  each 

finger  has  received  in  due  order 

the  same  circular  turn.      Complete  a  few  figure-of-S  turns  of  the  hand  and 

wrist. 

Demi-gauntlet  (Palmar).— Same  as  the  preceding,  except  that  the  oblique 


Fig. 


-The  Demi-gauntlet  Bandage  (Dorsal). 


BANDAGES  OF  TIIK  TUUNK  AND  ICXTREMITIKS 


421 


turns  from  the  wrist   to  the  base  of  the  finger  are  passed  over  the  palmar 
instead  of  the  dorsal  surface. 

The  Gauntlet  (Fig.  223).— 
Roller  one  inch  wide,  three  j-ards 
long.  Application:  Fix  the  in- 
itial extremity  by  means  of  one 
or  two  circular  turns  at  the  wrist. 
Cari-y  the  roller  by  an  obliciue 
turn  to  the  tip  of  the  thumb  and 
cover  the  latter  by  spiral  or  re- 
versed spiral  turns.  The  ban- 
dage is  then  carried  back  to  the 
wrist  and  a  circular  turn  made 
around  it,  then  carried  to  the 
index-finger,  which  is  bandaged 
in  the  same  manner  as  the  thumb. 
In  like  manner  the  remaining  fin- 
gers are  covered,  the  bandage  be- 
ing completed  by  a  few  circular 
turns  at  the  wrist  and  there  fast- 
ened, or  a  few  additional  figure- 
of-8  turns  may  be  passed  around 
the  hand  and  wrist  for  further 
security. 

Ascending  Single  Spica  of 
the  Groin  (Fig.  224).— Roller 
three    inches    wide,    eight    yards 


Fig.  223. — The  Gauntlet. 


long.  Application:  Fix  the  initial  extremity  of  the  bandage  by  means 
of  one  or  two  circular  turns  just  above  the  level  of  the  iliac  crests.  If  the 
right  grom  is  the  one  to  be  covered  in,  the  roller  should  run  anteriorly  from 

left  to  right,  and  in  the  reverse 
direction  in  the  case  of  the  left 
groin.  Carry  the  roller  from  the 
summit  of  the  ihac  crest  oppo- 
site the  groin  to  be  bandaged, 
obliquely  across  the  anterior  sur- 
face of  the  abdomen  to  the  outer 
side  of  the  thigh  of  the  affected 
side  at  the  junction  of  its  middle 
and  upper  third.  A  circular  turn 
and  a  half  is  now  made  around 
the  thigh  at  this  point,  the  roller 
finally  emerging  on  the  inner 
side  of  the  thigh,  whence  it  is 
carried  obliquely  across  the  front 
of  the  latter,  crossing  the  first 
oblique  part  as  low  down  as  pos- 
sible in  the  middle  line  of  the 
thigh,   thence  over  the  groin  to 


Fig.  224. — Ascending  Single  Spica  of  the  Groin. 


422 


BANDAGING 


Fig.  225. — Descexdixg  Single  Spica  of  the  Groin. 


the  lateral  aspect  of  the  ilium  of  the  same  side,  then  around  posteriorly  in 
a  slightly  oblique  direction  to  the  iliac  crest  of  the  side  from  which  it  started. 

A  circular  turn  is  now  made 
around  the  body  just  above  the 
iliac  crest  as  in  the  first  turn 
which  secured  the  initial  extrem- 
ity. The  spica  turns  are  alter- 
nated with  the  circular  turns 
around  the  body,  the  circular 
turns  around  the  thigh  each 
ascending  one-third  of  the  width 
of  the  bandage  and  the  spica 
turns  also  ascending  one-third 
of  their  width.  In  this  manner 
the  upper  third  of  the  thigh 
and  all  of  the  groin  is  completely 
covered  in.  The  circular  turn 
around  the  body,  or  that  around 
the  thigh,  or  both,  are  sometimes 
omitted.  The  spica  turns  should 
cross  each  other  exactly  in  the 
middle  line  of  the  thigh  and 
groin.  If,  in  bandaging  the  right  thigh,  the  bandage  is  started  around  the 
body  from  right  to  left,  instead  of  from  left  to  right,  the  roller  will  be  carried 
obliquely  across  the  groin  from 
the  lateral  surface  of  the  iliac 
crest  of  the  affected  side  to  the 
internal  aspect  of  the  thigh  at 
the  junction  of  its  middle  and 
upper  third.  Here  a  circular 
turn  and  a  half  is  made.  The 
roller,  emerging  on  the  outer 
side  of  the  thigh,  is  carried 
across  the  anterior  surface  of 
the  thigh,  crossing  the  first  ob- 
lique part  in  the  middle  line  of 
the  thigh  as  low  down  as  possi- 
ble, and  is  carried  obliquely 
across  the  anterior  surface  of  the 
abdomen  to  the  iliac  crest  of  the 
opposite  side,  and  thence  circu- 
larly around  the  body  to  its 
starting-point.  If,  in  bandag- 
ing the  left  groin,  the  roller  is 
started  from  left  to  right,  the 
above  description  also  holds  good 
for  that  side. 

Descending   Single    Spica   of   Groin    (Fig.   225). — Roller    three  inches 
wide,  eight  yards  long.     Application:   The  descending  spica  of  the  groin  is 


Fig.  226. — Ascending  Spica  of  Both  Groins. 


BANUAGKS  OF  THE  TRUNK  AND  KXTIIKMITIES 


423 


applied  in  the  same  manner  as  the  aseen(Un<^  spica,  and  consequently  the  same 
des{'i'i])ti()n  and  rules  hold  good  for  both,  with  the  exception  that,  whereas  in  the 
case  of  the  ascending  spica  the  first  spica  turn  is  placed  at  the  junction  of  the 
middle  and  upper  third  of  the  thigh,  and  the  subsecjuent  spica  turns  ascend 
from  that  point  one-third  of  their  width,  in  the  case  of  the  descending  spica 
the  first  spica  turn  is  ))laced  as  high  as  possible  and  the  subsequent  spica  turns 
descend  one-third  of  their  width  until  the  junction  of  the  middle  and 
upper  third  of  the  thigh  is  reachetl. 

Ascending  Spica  of  Both  Groins  (Fig.  226). — Roller  three  inches  wide, 
ten  yards  long.  Application:  Fix  the  initial  extremity  of  the  bandage 
by  means  of  one  or  two  cir- 
cular turns  around  the  body 
just  above  the  level  of  the 
iliac  crests.  The  roller  runs 
from  left  to  right  or  from  right 
to  left  according  to  the  thigh 
which  is  to  receive  the  first 
spica  turn.  From  the  iliac 
crest  of  one  side,  the  roller 
is  carried  obliquely  across 
the  anterior  surface  of  the 
abdomen  and  groin  to  the 
external  surface  of  the  oppo- 
site thigh  at  the  junction  of 
its  middle  and  upper  third. 
Here  make  a  circular  turn 
and  a  half,  emerge  from  the 
inner  side  of  the  thigh  ob- 
liquely across  the  first  ob- 
lic{ue  part  in  the  middle  line 
as  low  down  as  possible  on 
the  thigh,  ascend  obliquely 
to  the  lateral  surface  of  the 
ilium  of  the  same  side,  thence 
obliquely  around  the  body 
posteriorly  to  the  opposite 
iliac  crest.  Now  carry  a  cir- 
cular turn  around  the  body 
ending  abov^e  the   iliac  crest 

opposite  the  groin  yet  to  be  encircled.  Proceed  obliquely  across  the  back 
■  to  the  lateral  aspect  of  the  iliac  bone  of  the  opposite  side  and  thence  obliquely 
over  the  anterior  surface  of  the  groin  of  that  side  to  the  interior  surface  of  the 
thigh  at  the  junction  of  its  middle  and  upper  third.  Here  make  a  circular 
turn  and  a  half,  and,  emerging  on  the  external  surface  of  the  thigh,  ascend 
obliquely  over  the  anterior  surface  of  the  groin,  crossing  the  first  part  of  this 
spica  turn  in  the  middle  line  of  the  thigh.  Carry  the  roller  on  obliquely  over 
the  anterior  surface  of  the  abdomen  to  the  opposite  iliac  crest.  Here  make  a 
circular  turn  around  the  body.  These  turns  are  repeated  in  order,  first  a 
circular  one   around   the  body,   then  a   spica  turn  around  one  groin  which 


Fii 


-Double  Descen'dixg  Spica  of  Groix. 


424 


BANDAGING 


Fig.  228. — Volkmann's  Block. 


emerges  from  the  outer  side  of  the  thigh  after  surrounding  it  by  a  circular 
turn,  then  a  circular  turn  around  the  body  until  both  groins  and  the  upper 
thirds  of  both  thighs  are  completely  covered  in,  the  circular  turns  around 
the  thigh  ascending  one-third  of   their  width,  and  the  spica  turns  of    both 

groins  ascending  likewise  one-third 
of  their  width.  Either  the  circular 
turns  around  the  body  or  the  circular 
turns  around  the  thighs  or  both  may 
be  omitted.  The  bandage  is  fast- 
ened at  its  intersections  at  the  back 
over  the  anterior  surface  of  the  abdo- 
men and  also  at  the  spica  intersec- 
tions on  the  thigh  and  groin. 

Descending  Spica  of  Both  Groins 
(Fig.  227). — Roller  three  inches  wide, 
ten    yards    long.     Application:    The 
descending    spica    of    both   groins  is 
applied  in  the  same  manner  as   the 
ascending   spica,  with  the  exception 
that   the    oblique    turns    in    the   de- 
scending spica  begin  to  cross  high  up  and  descend  to  the   junction  of   the 
middle    and    upper   third    of  the    thigh    by  one-third   of    the   width    of   the 
roller.     Otherwise  the  bandage  is  applied  in  the  same  manner. 

In  applying  the  spicas  of  the  groin  the  patient  should  be  raised  from  the 
table  and  supported  on  a  V  o  1  k  m  a  n  n  '  s  block  (Fig.  228) .     In  the  absence 
of  the  latter,  an  inverted  basin  an- 
swers the  purpose. 

Figure-of-8  of  Knee  (Fig.  229). 
— Roller  three  inches  wide,  six 
yards  long.  Application:  Fix  the 
initial  extremity  of  the  bandage  by 
means  of  one  or  more  circular  turns 
a  short  distance  below  the  knee- 
joint.  Carry  the  roller  obliquely 
across  the  popliteal  space,  the  first 
oblique  turn  crossing  the  middle 
line  to  the  inner  surface  of  the  thigh. 
Here  make  a  circular  turn,  followed 
by  a  second  which  overlaps  the  first 
by  two-thirds  of  its  width  and  ap- 
proaches the  knee-joint  by  one- 
third  of  its  width.  Again  cross  the 
popliteal  space  to  the  circular  turns 
below,  and  here  make  another  cir- 
cular turn  which  ascends  toward  the 

knee-joint  by  one-third  of  its  width.  Continue  to  make  circular  turns  above 
and  below  the  knee,  the  upper  ones  gradually  ascending  until  the  knee  is 
entirely  and  securely  covered. 

Spiral  of  the  Foot. — Roller  two  inches  wide,  five  yards  long.     Applica- 


FlG.    229. FlGURE-OF-S    OF    THE    KnEE. 


BANDAGES  OF  THE  TRUNK  AND  EXTREMITIES 


425 


Fig.    230. — Figure-of-S    of 
THE  Foot  and  Ankle. 


tion :  Fix  the  initial  extremity  above  the  internal  malleolus  with  the  finger- 
tips of  the  left  hand.  Carry  the  roller  around  the  ankle  aiiteriorly  to  "the 
point  of  commencement,  crossinp;  the  initial  extrem- 
ity and  then  fixing  it.  The  roller  now  crosses  the 
instep  to  tiie  base  of  the  toes.  Here  a  circular  turn 
is  made,  and,  succeeding  this,  spiral  turns  ascend  the 
foot  and  instep  as  far  as  the  conformity  of  the  parts 
permit.  The  roller  is  then  carried  to  the  ankle;  a  few 
circular  turns  are  here  made,  and  the  terminal  ex- 
tremity fastened. 

Figure-of-8  of  Foot  and  Ankle  (Fig.  230).— 
Roller  two  inches  wide,  five  }'ards  long.  Applica- 
tion: Fix  the  initial  extremity  of  the  bandage  as 
in  applying  the  spiral  of  the  foot.  Carry  the  roller 
obliquely  across  the  instep  to  the  base  of  the  toes. 
Here  make  a  circular  turn.  Return  to  the  outer 
malleolus  atid  make  a  circular  turn  around  the 
ankle.  Continue  these  turns,  one  around  the  ankle, 
then  one  around  the  foot,  the  ankle  turns  gradually 
descending  until  the  foot,  instep,  and  ankle  are  cov- 
ered. Then  complete  by  a  circular  turn  around  the 
ankle,  and  fasten. 

Reversed  Spiral  of  the  Foot. — Roller  two  inches 
wide,   five    yards   long.      Application:    Same   as   the 

spiral  bandage  except  that  the  spiral  turns  of  the  foot  and  instep  are  replaced 

by  reversed  spiral  turns. 

Spica  of  the  Foot  (Fig.  231).— Roller  two 
inches  wide,  five  yards  long.  Application:  Fix 
the  initial  extremity  as  in  applying  the  other 
foot  bandages.  Carry  the  roller  obliquely  across 
the  instep  to  the  lateral  aspect  of  the  foot,  along 
the  lateral  aspect  to  the  posterior  surface  of  the 
heel  low  down,  thence  along  the  lateral  aspect  of 
the  foot  obliquely  across  the  instep,  crossing  the 
corresponding  oblique  turn  to  the  other  side  of 
the  foot  in  the  median  line.  This  completes  the 
first  spica  turn.  Repeat  these  spica  turns,  ascend- 
ing by  one-third  the  width  of  the  bandage  each 
time,  until  the  foot  and  ankle  are  covered  in. 
Then  complete  by  circular,  spiral,  or  spiral  re- 
versed turns  around  the  ankle.  A  few  spiral  or 
reversed  spiral  turns  applied  around  the  instep 
before  beginning  the  spica,  and  similar  turns 
about  the  ankle  on  completion  of  the  spica,  add 
to   the   neatness  of    the    bandage.     The    spica 

Fig.  2.31.-SPICA  of  the  Foot.  p^^^^g  gj^^^j^  ^^^^.^^^  ^^  -^  ^j^^  median  line. 

Recurrent  of  Foot. — This  is  simply  one  of 
the  usual  bandages  of  the  foot  among  whose  turns  are  included  recurrent 
turns  to  cover  in  the  toes. 


426 


BANDAGIXG 


Serpentine  of  the  Foot  (Fig.  232). — Roller  two  and  a  half  inches  wido, 
seven  yards  long.  Application:  The  initial  extremit}'  of  the  bandage  is  fixed 
in  the  same  manner  as  in  the  case  of  other  bandages  of  the  foot.  The 
roller  is  carried  obliquely  across  the  instep  to  the  base  of  the  toes,  where 
a  circular  turn  and  a  half  is  made,  bringing  the  roller  to  the  middle  line 
anteriorly.  Now  carry  the  roller  obliquely  to  the  outer  edge  of  the 
sole  uncier  the  hollow  arch  of  the  foot  to  the  interior  lateral  aspect  of 
the  heel  low  down,  thence  obliquely  up  over  the  posterior  aspect  of  the 
heel  to  the  external  malleolus.  Here  make  a  circular  turn  around  the 
ankle.  This  is  turn  number  one.  Then  obliciuely  across  the  instep  to 
the  base  of  the  toes,  the  roller  naturally  coming  to  the  internal  aspect  of 
the  base  of  the  toes,  whereas  in  turn  number  one  it  came  to  the  external 
aspect.  Take  a  circular  turn  and  a  half  around  the  base  of  the  toes  as  in 
turn  number  one.  Thence  obliquely  over  the  instep  to  the  internal  edge  of 
the  sole  of  the  foot,  on  around  beneath  the  hollow  arch  of  the  foot  obliquely 

to  the  external  lateral 
aspect  of  the  heel  low 
do^^^l,  thence  obliquely 
up  over  the  posterior 
aspect  of  the  heel  to  the 
internal  malleolus.  Now 
make  a  circular  turn 
around  the  ankle.  This 
is  turn  number  two. 
Turn  number  three  is 
simply  a  circular  turn 
around  the  instep  and 
point  of  the  heel,  its 
edges  being  held  and 
covered  in  by  a  repeti- 
tion of  turns  one  and 
two,  so  that  the  heel 
is  completely  covered. 
Turns  one,  two,  and 
three  are  repeated  until 
the  parts  are  covered. 
A  few  spiral  turns  above  the  malleoh  complete  the  bandage. 

Combinations  of  Spiral,  Reversed  Spiral,  Spica,  and  Figure-of-8. — 
Recurrent  and  serpentine  bandages  of  the  foot  may  be  used  as  indications  for 
them  arise  in  individual  cases.  It  is  sometimes  necessary  in  strapping  the 
joint  to  carry  spiral  or  reversed  spiral  turns  above  the  ankle.  This  may  also 
he  done  to  add  finish  to  a  bandage. 

If  it  is  not  necessary  to  cover  in  the  heel,  the  circular  turns  of  the  heel  and 
instep  should  be  omitted.  If  the  toes  are  to  be  covered,  recurrent  turns  may 
"be  introduced.  This  bandage  is  the  best  of  the  foot  bandages,  as  it  is  easy  to 
apply  and  stays  firmly  in  place. 

Reversed  Spiral  of  Lower  Extremity  (Fig.  233)  .—Roller  two  and  one-half 
inches  wide,  seven  yards  long.  Application:  One  of  the  foot  bandages  is 
first  applied,  except  that,  instead  of  ending  the  bandage  at  the  ankle,  the 


Fig.  232. — Serpentine  of  the  Foot. 


BANDAGES    OF   TIIK   TRUXK   AND    EXTREMITIES 


427 


Toiler  is  oarriod  up  the  lee;  by  means  of  spiral  or  reversed  spiral  turns  according 
to  the  sluipe  of  the  linib,  until  the  knee  is  reached.  The  bandage  may  be  ended 
here  with  a  few  circular  turns,  or,  witli  the  leg  in  the  extended  position,  it  may 
be  continued  on  up  the  thigh  to  the  groin,  and  either  end  there,  or  a  spica  of  the 
groin  may  be  added  for  additional  security.  If  it  is  desirable  to  leave  the 
l)atient's  knee  in  a  flexed  position,  a  figure-of-8  bandage  of  the  knee  may  take 
the  place  of  the  spiral  or  nn-ersod  spiral  turns  covering  in  that  region. 


Fig.  233. — Reversed  Spiral  of  Lower  Extremity. 

Figure-of-8  of  Leg  (Fig.  234). — Roller  two  and  one-half  inches  wide,  seven 
yards  long.  Application:  If  the  leg  is  fairly  well  molded,  this  is  the  best 
bandage  to  use.  First  apply  one  of  the  foot  bandages.  Then  ascend  the  leg 
by  means  of  spiral  or  spiral  reversed  turns  until  the  lower  part  of  the  calf  is 
reached.  Here  the  figure-of-8  turns  begin.  The  bandage  is  carried  obliquely 
upward  and  around  to  the  median  line  posteriorly,  whence  it  is  carried  obli- 
queh'  downward  and  around  to  the  front  of  the  leg,  crossing  the  starting  turn 
as  near  the  median  line  as  is  permissible  Avithout  bringing  too  much  pressure 
over  the  long  ridge  of  the  tibia.     These  figure-of-8  turns  are  repeated,  gradually 


^H 

■ 

H 

Fl 

^^^^H 

WM 

HF^ 

J 

:  1 

^^W 

WTu 

J 

' '     ' 

'             ;       1 

i     1             ■  ^^ 

•-■   .  ^ 

j 

^^^^^^^^H 

/-^-  _    ~ 

^^^^^^1 

K^^ 

.^ 

^^gUM 

■ 

Fig.  234. — Figure-of-8  of  Leg. 


ascending  the  leg  until  the  calf  is  covered.     The  bandage  is  completed  by  one  or 
more  circular  turns  around  the  leg  just  below  the  knee. 

Spica  of  Great  Toe  (Fig.  235). — Roller  one  inch  wide,  five  yards  long. 
Application:  This  is  applied  in  a  manner  similar  to  that  employed  in  the 
spica  of  the  thumb.  The  initial  extremity  of  the  roller  is  fastened  by 
one  or  two  circular  turns  around  the  ankle.  The  bandage  then  crosses  the 
instep  of  the  foot  obliquely  from  the  internal  malleolus  to  the  outer  side  of 


428 


BANDAGING 


the  great  toe.  A  circular  turn  is  taken  around  the  toe  as  near  the  tip  as 
possible  and  the  roller  carried  from  the  inner  side  of  the  toe  obliquely  across 
the  instep,  crossing  the  first  oblique  part  as  near  the  end  of  the  toe  as  possible 
to  the  hiternal  malleolus.  Here  a  circular  turn  is  made.  If  desirable,  the  tip 
may  be  covered  in  by  a  few  recurrent  turns.  The  spica  turns  are  repeated, 
ascending  toward  the  base  of  the  toe  each  time  one-third  the  width  of  the 

bandage  until  the  toe  is  completely  covered. 

Serpentine  of  Great  Toe. — Roller  one  inch 
wide,  six  yards  long.  Application:  The  initial 
extremity  of  the  bandage  is  fastened  by  means 
of  one  or  two  circular  turns  around  the  ankle. 
The  roller  is  then  carried  obliquely  across  the 
instep  to  the  outer  edge  of  the  sole,  then  ob- 
liquely under  the  sole  to  a  point  just  posterior  to 
the  thenar  eminence.  It  is  here  brought  to  the 
inner  edge  of  the  foot,  thence  across  the  anterior 
surface  of  the  base  of  the  toe  to  its  tip.  Here  a 
circular  turn  is  made  and  a  few  recurrent  turns 
may  be  added.  From  the  tip  the  roller  crosses  the 
anterior  surface  of  the  base  of  the  toe  to  its  tip. 
Here  a  circular  turn  is  made  and  a  few  recurrent 
turns  may  be  added.  From  the  tip  the  roller 
crosses  the  anterior  surface  of  the  base  of  the  toe 
and  thence  obliquely  across  the  base  of  the  other 
toes  to  the  outer  side  of  the  foot  at  a  point  opposite  the  hypothenar  emi- 
nence. It  passes  the  hollow  obliquely  just  behind  the  thenar  eminence  to 
emerge  at  the  inner  edge  of  the  foot,  thence  oblicjuely  across  the  instep  to  the 
exterior  malleolus.  Here  a  circular  turn  around  the  ankle  is  made.  These 
serpentine  turns  are  repeated,  each  overlapping  the  preceding  one  to  a  slight 
extent  until  the  toe  is  completely  covered. 


Fig.  235. — Spica  of  Great  Toe. 


PART  II 
REGIONAL  SURGERY 


SECTION  XIV 
THE  SURGERY  OF  THE  HEAD 

THE  SCALP 

The  thinner  portions  of  the  cranium,  as,  for  instance,  the  temporal  regions, 
are  covered  with  a  rather  thick  cushion — the  temporal  muscle ;  but  with  this 
exception  the  bones  of  the  skull  are  practically  unprotected.  The  epicranial 
structures  are  stretched  across  the  skull  in  such  a  manner  that  force  applied 
affects  soft  parts  and  bone  alike.  The  elasticity  of  the  cranial  vault  is  such, 
however,  that,  on  account  of  its  peculiar  conformation,  it  may  return  to  its 
normal  shape  after  quite  a  severe  blow  and  only  a  contusion  of  the  soft  parts 
result. 

Simple  contusions  of  the  scalp  are  usually  of  but  slight  importance 
and  require  no  treatment;  the  extra vasated  blood  is,  as  a  rule,  rapidly  resorbed. 
The  slightest  abrasion  of  the  integument,  however,  should  be  treated  antiseptic- 
ally  because  of  the  readiness  with  which  inflammatory  infection  takes  place  in 
this  region. 

Hematoma  of  the  scalp  results  from  rupture  of  one  or  more  vessels  of  con- 
siderable size.  The  subcutaneous  and  subaponeurotic  varieties  are  recognized. 
In  the  first  named  variety  a  fluctuating  swelling  surrounded  by  an  indurated 
border  is  present.  Owing  to  the  soft  and  apparently  depressed  center,  this 
condition  is  sometimes  mistaken  for  a  fracture  of  the  skull.  This  mistake  may 
be  avoided  by  noting  the  fact  that  the  indurated  margin  is  above  the  level  of 
the  surrounding  bone,  and,  in  addition,  that  it  pits  on  pressure.  In  the  second 
variety,  namely,  that  which  occurs  beneath  the  aponeurosis  of  the  occipitofron- 
talis  muscle,  the  effusion  of  blood  may  separate  the  latter  from  the  bone  for 
a  large  area,  giving  rise  to  bulging  at  the  supraorbital  ridges  and  in  the  occipital 
region.  In  the  treatment  of  a  large  hematoma  it  may  become  necessary  to 
resort  to  incision  and  evacuation  of  the  clots  and  fluid  blood,  with  subsecjuent 
drainage. 

Wounds  of  the  scalp  gape  considerably,  provided  they  penetrate  to 
the  bone  and  are  transverse;  otherwise  they  do  not.  This  is  due  to  the 
peculiar  anatomic  structure  of  the  connective  tissue  between  the  scalp  and  the 
pericranium,  the  bony  elastic  fibers  of  which  permit  the  retraction  of  the 
edges  in  both  directions  by  the  action  of  the  occipitofrontalis  when  the  entire 

429 


430 


THE   SURGERY   OF   THE    HEAD 


thickness  of  the  scalp  is  traversed  by  the  wound.  Sharp  pointed  instruments, 
easily  penetrate  to  the  bone,  but  rarely  pass  through  it,  unless  directed  with 
great  force. 

The  treatment  of  incised  wounds  of  the  scalp  requires  on  the  part  of  the 
surgeon  the  arrest  of  hemorrhage  as  his  first  care.  The  vascularity  of  the  parts- 
is  such  that  considerable  blood  may  be  lost  before  spontaneous  arrest  takes 
place.  The  rigid  fibers  of  the  aponeurotic  connective  tissue  in  the  scalp,  like 
the  walls  of  the  bony  canals,  prevent  retraction  of  the  divided  arteries  and 
narrowing  of  their  lumina.  Artificial  means  for  the  arrest  of  hemorrhage  are 
therefore  quite  necessary  in  this  region.  The  application  of  a  ligature  in  the 
ordinary  manner  is  often  impracticable,  and  if  coaptation  and  suturing  do  not 
suffice,  a  ligature  must  be  passed  through  the  scalp  by  means  of  a  needle  in  such 
a  manner  as  to  surround  the  bleeding  point  (circumsuture),  and  must  be  tightly 
tied.     This  suture  may  be  so  applied  as  to  avoid  puncturing  the  skin,  and 

thus  there  is  no  risk  of  infection 
from  that  source.  Oozing  from  the 
edges  of  the  wound  after  suturing 
may  usually  be  arrested  by  a  snugly 
applied  bandage  holding  the  dress- 
ings in  position.  The  solid  bone 
beneath  admits  of  the  application  of 
considerable  pressure. 

Contused  wounds,  though  pro- 
duced by  a  blunt  object,  because  of 
the  tense  state  of  the  scalp  and  the 
presence  of  the  smooth  bony  wall  of 
the  skull  in  close  proximity,  resemble 
incised  wounds  at  their  edges.  The 
rupture  of  the  vessels,  however,  is 
quite  irregular  or  ragged,  thus  favor- 
ing coagulation  of  blood  and  sponta- 
neous arrest  of  hemorrhage. 

It  was  formerly  the  custom  to  per- 
mit such  wounds  to  close  by  granula- 
tion, on  account  of  the  fear  of  exten- 
sive  suppurative   inflammation   of    the    scalp.     With   aseptic    or   antiseptic 
wound  treatment,  however,  contused  and  lacerated  wounds,  after  their  edges 
have  been  trimmed  with  the  knife  or  scissors,  may  now  be  sutured  at  once. 

Avulsion  of  the  Scalp. — This  usually  occurs  in  women  from  machinery 
accidents,  the  long  hair  becoming  entangled  between  the  belt  and  the  pulley  of 
shafting  or  of  a  machine.  The  avulsion  may  be  partial;  usually,  however, 
the  entire  scalp  is  torn  from  the  head,  leaving  the  pericranium  exposed.  All 
or  portions  of  the  ears  and  upper  eyelids,  as  well  as  the  integument  and 
subcutaneous  connective  tissue  of  the  back  of  the  neck,  and  portions  of  the 
temporal  muscles,  may  be  included  in  the  avulsion  (Figs.  236  and  237).  The 
cranial  bones  may  be  denuded  of  periosteum  in  places.  The  degree  of  shock 
present  and  the  amount  of  blood  lost  vary  greatly.     Death  may  result  from 


Fig.  236. — Avulsion  of  the  Scalp. 


these  causes  alone, 
usually  takes  place. 


Where  the  periosteum  is  torn  off,  exfoliation  of  bone^ 


THE    SCALP 


431 


Treatment. — These  accidents  most  coininonly  occur  in  anemic  and 
poorly  nourished  factory  operatives.  The  loss  of  blood,  together  with  the 
prolonged  drain  on  the  system  incident  to  the  constant  oozing  of  serum  from  so 
large  a  granulating  surface,  demands  that  the  period  of  healing  be  shortened  as 
much  as  possible.  For  this  reason  the  surgeon  should  not  await  the  results  of 
nature's  efforts  before  interfering,  but,  on  the  recover}'  of  the  patient  from  the 
shock,  he  should  at  once  commence  the  treatment  by  skin-grafting.  The 
method  of  Thiersch  should  be  employed.  The  strips  are  to  be  taken  from 
the  outer  portions  of  the  thighs  as  long  as  these  regions  are  available;  sub- 
sequently they  may  be  taken  from  the  legs  and  arms.  In  the  beginning  the 
strips  should  be  placed  adjacent  to  the  skin  edges,  and  successive  strips 
placed  in  position  from  time  to  time,  with  as  little  time  intervening  as  pos- 
sible. Care  should  be  taken  not  to  imperil  the  vitalit}^  of  the  strips  by  too 
tight  bandaging.  This  is  particularly  likely  to  occur  beneath  the  circular 
or  occipitofrontal  turns  of  the  head 
bandage. 

Simple  loosening  of  the  scalp 
without  avulsion  may  occur  from 
force  applied  in  the  same  manner  as 
in  the  case  of  a\nilsion.  the  force, 
however,  stopping  short  of  actually 
tearing  away  the  scalp.  This  is  fol- 
lowed by  extensive  hematoma  of  the 
scalp.  Moderate  compression  by 
means  of  a  bandage  usually  suffices 
in  the  treatment. 

Inflammation  Following  In- 
juries of  the  Scalp. — The  tissues  of 
the  scalp  are  not  specially  disposed 
to  inflammation.  "N^Tien  an  inflam- 
matory process  follows  an  injury,  in 
the  case  of  the  skin  covering,  it  as- 
sumes an  erysipelatous  character ;  in 
the  connective  tissue  it  is  phleg- 
monous.    In    preaseptic    times    the 

former  was  of  very  frec^uent  occurrence  after  sutured  wounds  of  the  scalp; 
now,  however,  it  is  comparati^'ely  rare. 

A  special  feature  of  erysipelas  attacking  the  scalp  should  not  be  lost  sight  of. 
The  redness  observed  in  other  localities  as  one  of  the  symptoms  of  erysipelas 
is  here  replaced  by  a  pale  edematous  swelling  which  spreads  to  the  lower  margins 
of  the  scalp.  This  is  probably  due  to  the  fact  that  the  tension  of  the  tissues  of 
the  scalp  pressing  on  the  bony  wall  beneath  prevents  the  overfilling  of  the  capil- 
laries. For  this  reason  an  edematous,  puffy  state  of  the  scalp,  accompanied  by 
a  rigor  and  elevation  of  temperature,  should  be  looked  on  with  suspicion  as  the 
possible  initial  stage  of  an  attack  of  erysipelas. 

The  special  danger  to  be  apprehended  from  erysipelas  of  the  scalp  is  the 
occurrence  of  traumatic  meningitis  (see  page  457).  The  cortex  of  the  brain 
may  finally  take  part  in  the  inflammatory  process  (encephalitis,  see  page  458). 
A  fatal  termination  is  the  rule  in  these  cases,  delirium  and  coma  supervening. 


Fig.  237. — Avulsion  of  the  Scalp. 


432  THE  SURGERY  OF  THE  HEAD 

A  fatal  septic  meningitis  may  also  follow  a  phlegmonous  inflammation  of 
the  connective  tissue  between  the  aponeurotic  structures  of  the  scalp  and  the 
cranium.  Here  the  direct  communication  between  the  veins  in  this  region  and 
those  of  the  diploe,  and  between  the  latter  and  those  of  the  cerebral  membranes, 
favors  infection  by  thrombosis.  The  thrombi,  after  putrefying  and  softening, 
ma}'  become  displaced  and  finally  be  transported  to  distant  parts,  causing  a 
fatal  pyemia.  The  occurrence  of  phlegmonous  inflammation  is  recognized  by 
the  extreme  edema,  the  scalp  pitting  on  pressure  and  giving  rise  to  acute 
tenderness  and  severe  pain  accompanied  by  high  fever.  Fluctuation  is  not 
usually  present. 

Phlegmonous  inflammation  and  erysipelas  may  be  combined  here  as  else- 
where. "\Mien  the  erysipelas  reaches  the  lower  margin  of  the  scalp  the  skin 
becomes  reddened.  Phlegmonous  inflammation  is  soon  followed  by  suppura- 
tion.    In  the  early  stages  the  two  cannot  be  differentiated. 

Treatment  of  Wounds  of  the  Scalp. — The  importance  of  a  strict  antiseptic 
procedure  in  cases  of  scalp  wounds  cannot  be  overestimated.  Est  lander 
has  shown  by  a  careful  study  of  the  subject  that  in  preantiseptic  times  the 
mortality  from  this  class  of  injuries  was  23  per  cent.  With  antiseptic  wound 
treatment  this  mortality  has  been  reduced  to  1.5  per  cent.  While  the  general 
rules  governing  the  treatment  of  wounds  will  here  apply,  there  are  some  special 
points  to  be  noted  in  this  connection.  In  the  first  place,  a  large  area  of  the 
scalp  in  the  neighborhood  of  the  wound  must  be  carefully  shaved.  With- 
out this  25recaution  it  is  next  to  impossible  to  cleanse  the  scalp  so  thoroughly 
as  to  prevent  bacterial  infection.  Moreover,  exact  coaptation  of  the  edges 
of  the  wound,  as  well  as  the  accurate  ai^plication  of  dressings,  is  impossible 
in  the  presence  of  the  hair. 

All  traces  of  dirt  are  to  be  removed  by  the  brush,  soap,  and  hot  water,  and 
copious  irrigations  practised  before  suturing.  As  a  final  measure,  germicidal 
solutions  employed  for  irrigation  are  to  be  washed  away  by  means  of  sterile 
water  or  a  sterilized  normal  sodium  chlorid  solution.  The  best  suture  materials 
for  this  purpose  are  horsehair  and  crin-de-Florence  or  silkworm-gut.  The 
interrupted  suture  should  be  used.  In  cases  in  which  there  is  considerable 
oozing  from  the  skin  edges,  the  suture  should  always  include  the  entire  thick- 
ness  of  the  scalp. 

If  the  injury  is  the  result  of  an  accident  and  the  case  comes  to  the  surgeon's 
hands  shortly  after  the  accident,  and  if  no  special  infection  is  suspected,  wounds 
involving  the  entire  thickness  of  the  scalp  may  frec^uently  be  entirely  closed 
without  risk.  But,  as  a  rule,  drainage  should  be  provided  for.  This  may 
consist  simply  in  leaving  the  lowermost  angle  of  the  wound  open  for  a  c^uarter  of 
an  inch  or  more.  In  large,  flaplike  wounds  resulting  from  glancing  blows-,  in 
which  infection  is  always  to  be  suspected,  the  center  of  the  place  of  attachment 
of  the  flap  is  to  be  selected  and  a  counter-opening  for  drainage  made  at  this 
point.  Narrow  strips  of  oiled  silk  protective  make  an  excellent  drain  in  these 
cases. 

Wounds  made  in  the  course  of  an  aseptically  conducted  operation  are 
always  to  be  closed  without  drainage. 

■WTien  dressings  are  applied  to  wounds  of  the  scalp  they  should  include  the 
entire  head  after  the  wound  and  neighborhood  (which  should  also  be  shaved) 
have  been  completely  covered  by  separate  pieces  of  sterile  gauze.     A  recurrent 


THE    SCALP  433 

doul)l(>  voWvv  oi-  capoliiio  baiuhigc  (see  page  404)  to  secure  the  dressings  in  place, 
and  a  bandage  of  starched  crinoline,  thoroughly  wetted  and  stjueezed  out  before 
being  applied,  serve  to  conijilete  the  dressing.  The  starched  crinoline,  on  dry- 
ing, will  hold  the  dressings  firmly  in  position,  even  in  the  most  restless  patient. 
This  is  a  commercial  article  and  is  sold  in  the  dry-goods  stores  for  dressmaking 
and  tailoring  purposes.     Dextrin  and  glue  enter  into  its  composition. 

Careful  therniometric  observations  will  warn  the  surgeon  of  the  super\-ention 
of  a  septic  condition.  Er^-sipelas  and  phlegmonous  inflammation  should  be 
recognized  early,  and  on  their  occurrence  prompt  measures  of  treatment  should 
be  instituted  (see  Treatmentof  Erysipelas,  page  179).  In  case  of  phlegmonous 
or  suppurative  inflammation  the  dangers  of  pyemia  and  septic  meningitis  are 
imminent ;  free  incisions  should  be  made,  followed  by  the  vigorous  application 
of  the  sharp  spoon  to  clear  out  suppurating  foci.  The  wounds  are  subsequently 
to  be  packed  with  gauze  wrung  out  of  1 :  2000  mercuric  chloric!  solution  in  50 
per  cent  alcohol.  It  is  also  useful  to  cleanse  the  wound  thoroughly  with  a  5 
per  cent  zinc  chlorid  solution  and  pack  it  afterward  with  gauze  wrung  out  of  the 
same.  Even  in  those  cases  in  which  most  or  all  of  the  scalp  has  been  torn  off  l^y 
machinery  accidents  a  favorable  result  may  be  expected.  The  large  granulating 
surface,  after  it  has  assumed  a  healthy  aspect,  should  be  covered  in  b>-  the 
application  of  strips  of  skin  transplanted  after  Thiersch's  method  (see 
page  331). 

Tumors  of  the  Scalp. — Atheromas  or  sebaceous  cysts  of  the  scalp, 
sometimes  called  wens,  are  the  tumors  most  commonly  found  in  tliis  location. 
They  differ  from  dermoid  cysts  in  that  the  latter  are  always  congenital  and 
limited  to  certain  localities,  while  the  former  occur  almost  exclusively  in  adults 
and  on  almost  any  portion  of  the  scalp.  A  differential  diagnosis  of  these 
tumors  will  be  facilitated  if  their  location  is  taken  into  consideration.  The 
favorite  sites  for  dermoid  cysts  are,  in  order  of  frecjuency  of  occurrence  of  the 
cysts,  the  external  portion  of  the  supraorbital  arch,  the  point  where  the 
sagittal  and  coronal  sutures  join,  the  site  of  the  anterior  fontanel,  behind  and 
in  front  of  the  auricle. 

Dermoid  cysts,  when  uncomplicated  by  bony  defects,  as  well  as  sebaceous 
cysts,  are  to  be  extirpated  when,  because  of  their  size  or  from  any  other  cause, 
they  become  sources  of  discomfort.  The  best  method  of  accomplishing  this  is  to 
make  a  semicircular  incision  at  the  base,  turn  back  a  flap  which  shall  include 
the  entire  cyst  and  its  contents,  and  then  dissect  the  cj'st  from  the  flap.  In 
this  manner  the  cj^'st  does  not,  as  a  rule,  rupture,  and.  w^hat  is  of  greater  im- 
portance, the  entire  sac  is  removed.  Dermoid  cysts  in  the  neighborhood  of  the 
fontanel  are  frec^uently  complicated  by  an  opening  into  the  cranial  cavity,  which 
necessitates  extreme  care  in  their  removal. 

Aneurism  of  the  Scalp. — This  may  appear  either  in  the  shape  of  a 
circumscribed  saclike  dilatation  of  a  portion  of  a  single  vessel,  or  a  diffused 
cylindric  dilatation  of  a  number  of  the  arteries  of  the  scalp.  The  first  is  usually 
due  to  injury  of  the  wall  of  the  vessel,  and  not  infrequently  develops  in  the 
recent  cicatrix  after  a  punctured  or  glancing  wound.  Extirpation  is  the  only 
resource.  Care  should  be  taken  not  to  mistake  a  highly  vascular  sarcoma  of 
the  scalp  for  an  aneurism  of  this  kind.  Sarcoma  of  the  dura  which  has  per- 
forated the  bone  may  likewise  simulate  aneurism. 

Cirsoid  or  racemose  aneurism  occurs  almost  exclusively  in  the  arteries 
29 


434  THE  SURGERY  OF  THE  HEAD 

of  the  scalp  (see  page  94).  These  are  mcreased  in  both  circumference  and 
length,  the  latter  circumstance  producing  a  serpentine  course  and  wormlike 
appearance,  which  are  cjuite  characteristic  of  the  disease.  Its  origin  has  been 
attributed  to  congenital  conditions  (capillary  angioma),  to  vasomotor  paralysis, 
and  to  injury. 

Varices  of  the  scalp  have  also  been  observed  (cephalohematocele  of 
S  t  r  o  m  e  3'  e  r),  and  venous  cysts  situated  on  the  line  of  the  sagittal  suture 
and  communicating  directly  with  the  longitudinal  sinus. 

In  the  treatment  of  cirsoid  aneurism  many  difficulties  present  them- 
selves. Injections  of  solutions  of  perchlorid  of  iron  have  been  tried  with  fatal 
results  from  too  extensive  coagulation  and  extension  of  this  to  one  of  the 
smuses.  The  application  of  caustics  has  been  followed  by  fatal  hemorrhage 
on  separation  of  the  slough.  Ligation  of  the  external  carotid  artery  of  both 
sides  has  been  followed  by  recurrence,  owing  to  the  free  anastomosis  of  the 
arteries  of  the  scalp  with  the  vertebral  from  the  subclavian  through  the  circle 
of  Willis  to  the  frontal,  supraorbital,  and  internal  carotid  and  facial  branches. 
Dieffenbach  proposed  repeated  excision  of  fusiform  portions  of  the  scalp, 
each  w^ound  as  it  is  made  being  grasped  by  clamp  forceps  or  the  finger  of  an 
assistant,  hemorrhage  being  thus  held  in  check  until  the  application  of  close  and 
accurate  suturing.  The  wound  having  healed,  a  second  portion  is  to  be  ex- 
cised, and  so  on,  until  a  sufficient  amount  has  been  removed  to  cure  the  disease. 
Total  extirpation  of  the  entire  aneurismal  area  followed  by  immediate  cor- 
rection of  the  defect  by  skin  transplantation  holds  out  the  best  hope  of  cure. 
An  elastic  tourniquet  should  be  passed  around  the  head  to  hold  the  bleeding 
in  check  during  the  operation  (see  page  339,  Prophylactic  Arrest  of  Hemor- 
rhage). In  cases  of  extensive  involvement  of  the  scalp,  on  account  of  the 
danger  of  death  from  hemorrhage,  the  method  of  total  extirpation  at  a  single 
sitting  is  an  exceedingly  hazardous  one. 

Lipoma  of  the  scalp  occurs  only  in  the  low  occipital  region.  Fibromas  are 
limited,  as  a  rule,  to  the  frontal  region,  and  are  usually  the  result  of  hat  pres- 
sure; they  occur  as  hard  and  painful  tumors.  Fibromas  are  sometimes  simu- 
lated by  sebaceous  cysts  which  have  undergone  calcification. 

Sarcoma  of  the  scalp  is  an  exceedingly  rare  affection.  It  has  been  ob- 
served most  frecjuently  in  the  occipital  region.  Recurrence  in  the  cicatrix  after 
removal  is  the  rule.  Carcinoma  may  occur  as  rodent  ulcer  or  as  proliferating 
epithelial  carcinoma,  is  usually  confined  to  the  frontal  region,  and  may  appear 
at  the  site  of  a  suppurating  sebaceous  cyst. 


THE  CRANIAL  BONES 

Contusions  of  the  cranial  bones  as  described  by  the  older  surgeons  and 
considered  as  indications  for  trephining  because  of  resulting  necrosis  are  at  the 
present  day  admitted  only  as  possibilities. 

FRACTURES 
Fractures  of  the  cranial  bones  constitute  2.75  per  cent  of  all  fractures 
(G  u  r  1 1) .     The  bony  walls  of  the  cranial  vault  are  more  or  less  compressible 


THE    CRANIAL    BONES  435 

in  both  tlio  fronto-o(Tii)ital  and  the  l)ipan(>tal  diameter.     The  vertical  (Uameter 
ran  also  be  shghtl^-  altered  by  pressure  without  fracture.     Experiments  have 
8hc)\Nn  that  the  bone  almost  hivariably  gives  wav  in  the  line  of  pressure   {   e 
transA-crse  pressure  gives  rise  to  a  transverse  fracture  and  longitudinal'  pres- 
sure to  a  longitudinal  fracture. 

Fractures  of  the  cranial  bones  may  be  the  result  of  direct  or  indirect  force  • 
fractures  from  dn-ect  force  are  the  more  common  and  their  mechanism  is  very 
simple.  Fractures  from  indirect  force  result  from  the  transference  of  the  force 
to  the  skull  through  the  medium  of  the  vertebral  column,  as,  for  instance  when 
the  patient  falls  from  a  considerable  height  and  strikes  on  the  feet  One  or 
more  fractures  of  the  base  may  follow,  these  radiating  from  the  foramen 
magnum.  Or.  if  the  fall  is  on  the  vertex,  the  compressibilitv  of  the  skull  in 
this  direction  is  easily  exceeded,  but  the  diploe  acting  somewhat  as  a  buffer 
protects  the  vault  and  the  force  is  transferred  to  the  more  ri-id  and  unvielding 
base,  which  is  usually  fractured  at  a  point  opposite  the^  place  of  Wpact 
ihese  iractm-es  are  called  fractures  bv  contrecoup. 

Fractures  by  contrecoup  were  formerly  believed  to  be  very  common  and 
were  thought  to  be  the  result  of  vibrations  passing  around  the  cranium  and 
meetmg  at  the  pomt  at  which  the  fracture  occurred.  Thev  are  now  believed  to 
be  due  to  changes  in  the  shape  of  the  skull  through  the  compressibilitv  above 
referred  to,  the  pomt  opposite  that  at  which  the  blow  was  received  alt'erino-  in 
shape  to  a  less  extent  than  the  rest  of  the  bony  casing,  and  hence  giving  m  av 
Even  perforatuig  forces  ma.'  produce  a  second  fracture  opposite  the  point  of 
entrance  of  the  bullet  or  other  missile,  the  latter  not  reaching  the  pohit  at  which 
the  second  fracture  is  found. 

Fractures  of  the  skull  assume  various  forms,  according  to  the  degree  of  force 
and  the  shape  of  the  impinging  object.    A  sharp-edged  or  pointed  object  ..-ill  be 
hkely  to  produce  a  splintered  or  comminuted  fracture;  one  of  a  somewhat  larger 
surface,  a  star-shaped  or  stellated  fracture;  while  a  stOl  broader  surface,  such 
as  the  pavement,  commg  in  contact  ^ith  the  skull  mav  produce  one  or  more 
simple  fissures.     These  fissures  may  be  very  extensiv^,  taking  a  course  cir- 
cumferentially,  transversely,  or  longitudinallv,  and  dividing  the^cranial  encase- 
ment into  two  portions.     At  the  moment  of  their  occurrence  they  gape  con- 
sic  erabl}'    but  close  agam,  imprisoning  portions  of  the  aponeurosis  and  even 
ot  hair  when  the  fracture  is  complicated  by  an  external  wound  (compound  frac- 
ture)     The  basilar  artery  has  been  found  thus  imprisoned.     When  the  bone  is 
torced  inward  to  a  greater  or  lesser  extent  this  constitutes  a  depressed  fracture 
I  he  entrance  of  the  vulnerating  object,  such,  for  instance,  as  a  bullet  or  a  knife- 
blade,  gives  rise  to  a  penetrating  or  punctured  fracture.     The  latter  is  alwavs 
a  compound  complicated  fracture  and  comminuted  as  well.     All  fractures 
of  the  cranial  vault,  including  simple  fissure,  stellated  fractures,  and  depressed 
fracture^  of  greater  or  lesser  extent,  may   be   complicated  bv  an  external 
wound  (compound  fracture).     Certain  fractures  of  the  base  maV  also  be  com- 
pound, such,  for  mstance,  as  result  from  perforation  of  the  roof  of  the  orbit  as 
well  as  those  m  which  a  fracture  of  the  vault  complicated  with  an  external  wound 
extends  to  the  base.     While  a  fracture  of  the  vault  may  extend  to  the  base,  yet 
by  far  the  greater  number  of  combmed  fractures  of  the  base  and  vault  take  the 
op]3osite  course,  i.e.,  the  fracture  extends  from  the  base  to  the  vault     A  fracture 
oi  the  anterior  fossa  communicates  with  the  air  through  the  nasal  cavity  and 


436  THE  SURGERY  OF  THE  HEAD 

a  fracture  of  the  middle  fossa  through  the  auditory  canal.  This  i)articular 
feature  of  these  fractures  is  frequently  overlooked.  They  constitute  a  most 
dangerous  class  of  hijuries. 

In  comminuted  fractures  the  tables  of  the  skull  do  not  partake  of  the  splinter- 
ing process  to  the  same  extent.  This  occurs  most  freciuently  at  the  internal 
table  because  of  the  fact  that  the  greater  number  of  skull  fractures  are  produced 
by  violence  originating  from  without.  In  cases  in  which  the  force  is  applied 
from  within,  as,  for  instance,  where  a  buUet  passes  entirel}'  through  the  skull, 
while  the  point  of  entrance  will  show  the  greatest  amount  of  splintering  at  the 
mternal  table,  the  point  of  exit  will  reveal  exactly  the  reverse.  It  therefore 
must  be  apparent  that  the  formerly  accepted  theory,  that  the  brittleness  of  the 
internal  table  accounts  for  the  more  general  occurrence  of  splintering  at  this 
point,  is  incorrect.  In  the  usual  form  of  injury  from  without  inward,  the  inter- 
nal table  is  splintered  more  than  the  external  table,  simply  because  the  latter 
is  affected  only  by  the  force  which  is  applied,  while  the  former  suffers  from  this 
plus  the  effect  of  the  external  table  driven  against  it. 

Fracture  of  the  internal  table  may  occur,  the  external  table  escaping.  This 
is  due  to  the  curved  shape  of  the  cranial  vault.  The  molecules  of  the  bony 
structure  are  condensed  on  its  convex  surface,  while  the  force,  transmitted  to  the 
concave  or  inner  surface,  produces  separation  there.  After  the  fracture  of  the 
internal  table  the  outer  unbroken  table  returns  to  its  normal  position. 

Traumatic  separation  of  the  sutures  of  the  skull  occurs,  with  or  without 
fracture.  Separation  without  fracture  takes  place  almost  exclusively  at  the 
base.  Extensive  fissures  of  the  vault  may  communicate  with  one  or  more 
sutures,  the  line  of  force  following  the  latter  for  a  greater  or  lesser  distance, 
subsequently  leaving  this  sometimes  at  a  right  angle  and  ending  on  the 
surface  at  a  place  quite  remote  from  the  point  where  it  began. 

Fractures  of  the  base  are  almost  necessarily  of  the  fissured  variety,  except 
those  in  which  the  cavity  of  the  skull  is  invaded  directly,  as  by  a  bullet  or  other 
foreign  body.  These  fissures  may  pass  in  almost  any  direction  or  invade  any 
locality.  The  wings  of  the  sphenoid  bone  and  the  pyramids  of  the  petrous 
portion  of  the  temporal  bone  may  be  considered  as  two  systems  of  braces  which 
cross  the  base  of  the  skull  in  a  transverse  direction.  Fissures  of  the  base  pass  in 
a  direction  either  in  front  of  or  behind  these.  Transverse  fissures  are  more 
common  than  longitudinal  ones,  for  the  reason  that  a  much  greater  force  is 
recjuired  to  produce  the  latter.  In  the  posterior  fossa  the  fissure  frequently 
involves  the  edge  of  the  foramen  magnum,  crossing  the  latter,  as  it  were,  and 
passing  in  the  direction  of  the  lambdoidal  suture.  Or,  it  may  cross  the  sella 
turcica  of  the  sphenoid  and  reach  the  middle  fossa,  thence  turning  in  the  direc- 
tion of  the  squamous  portion  of  the  temporal  bone  and  the  greater  wing  of  the 
sphenoid.  Again,  a  short  longitudinal  fissure  may  communicate  with  the 
transverse  fissure,  pass  into  the  anterior  fossa,  and  invade  the  ethmoid  bone  at 
its  horizontal  plate,  passing  to  the  crista  galli..  Finally,  the  fracture  not  in- 
frequently passes  along  the  anterior  edge  of  the  petrous  portion  of  the  temporal 
bone  and  crosses  the  tympanum. 

Diagnosis  of  Fracture  of  the  Sl<ull. — The  signs  usually  present  in 
fractures  elsewhere  are  not  available  for  diagnostic  purposes  in  uncomplicated 
fractures  of  the  skull.  Crepitus  cannot  be  obtained  and  preternatural  mobility 
is  absent.     Even  depressed  fracture  is  frequently  difficult  of  recognition,  owing 


THE    CRANIAL    BONES  437 

to  the  effusion  of  blood  between  the  soft  parts  and  the  bone.  The  hemorrhage 
is  frequently  so  distinctly  circumscribed  as  to  mislead  the  surgeon  and  cause 
him  to  mistake  the  unresisting  soft  area  with  sharply  defined  solid  margins  for 
a  depressed  or  even  a  j)enetrating  fracture.  He  should  also  be  on  his  guard 
against  error  arising  from  mistaking  old  injuries,  syphilitic  diseases  with  loss 
of  bone  substance,  etc.,  for  depressed  fracture.  So,  too,  the  dishlike  depres- 
sion in  the  parietal  regions  resulting  from  atrophy  in  old  persons  may  give  rise 
to  similar  error. 

In  fractures  of  the  skull  complicated  with  an  external  wound  no  difficulty  is 
experienced  in  making  the  diagnosis,  except  that  care  should  be  taken  not  to 
mistake  a  suture  line  for  a  fissure.  The  Wormian  bones,  situated  at  the  pos- 
terior extremity  of  the  sagittal  suture,  should  likewise  be  borne  in  mind.  The 
point  of  the  disinfected  finger  is  preferably  employed  for  exploratory  purposes 
and  the  finger-nail  will  usually  reveal  the  existence  of  even  a  fissure.  A\liere 
the  external  wound  is  not  sufficiently  large  to  permit  satisfactory  exploration, 
it  should  be  enlarged  to  permit  inspection  of  the  fracture.  It  is  unnecessary 
to  state  that  all  manipulatiA'^e  procedures  should  be  preceded  by  the  strictest 
aseptic  precautions.  The  possible  existence  of  a  fracture  by  conirecoup  at  a 
point  opposite  the  place  at  which  the  blow  was  received  should  be  borne  in  mind 
in  making  the  diagnosis.  The  justifiability  of  converting  a  simple  fracture 
into  a  compound  one,  by  incising  the  scalp  for  exploratory  purposes,  will  de- 
pend on  the  presence  or  absence  of  cerebral  symptoms. 

Fractures  of  the  base,  except  in  those  cases  in  which  fracture  of  the  roof 
of  the  orbit  or  of  the  auditory  canal  results  from  direct  force,  are  not  amenable 
to  diagnosis  by  either  inspection  or  palpation.  Another  exception  relates  to 
those  instances  in  which  the  patient  falls  from  a  height  and  strikes  on  the  point 
of  the  chin,  the  inferior  maxilla  being  driven  through  the  glenoid  cavity  of  the 
temporal  bone.  In  fractures  of  the  base  reliance  is  to  be  placed  on  the  follow- 
ing signs:  (1)  hemorrhage  from  one  or  both  ears  with  or  without  discharge  of 
cerebrospinal  fluid;  (2)  hemorrhage  from  the  nasal  and  pharyngeal  cavities; 
(3)  subconjunctival  hemorrhage;  (4)  paralysis  of  individual  nerves  at  the  base 
of  the  skull. 

Hemorrhage  from  the  Ears. — This  may  occur  from  other  causes,  such  as 
injuries  to  the  external  auditory  apparatus  and  rupture  of  the  membrana  tym- 
pani.  AYhen  due  to  fracture,  the  latter  runs  along  the  line  of  the  pyramid 
of  the  petrous  portion  of  the  temporal  bone,  and  the  blood,  mingled  with 
cerebrospinal  fluid,  escapes  externally  through  the  ruptured  membrana  tym- 
pani.  After  cessation  of  the  hemorrhage  cerebrospinal  fluid  may  continue  to 
pour  from  the  ear  in  large  quantities.  This  fluid,  though  rarely,  may  escape 
from  the  nose  and  the  pharnyx.  If  it  is  collected  in  a  vessel,  the  presence  of 
sugar  can  be  demonstrated  (C  1  a  u  d  e  B  e  r  n  a  r  d).  It  is  also  characterized 
by  an  extremely  small  amount  of  albumin  and  a  relatively  large  amount  of 
sodium  chlorid.  The  existence  of  a  considerable  pressure — that  of  the  circu- 
lation— is  proved  by  this  discharge.  The  ciuantity  of  fluid  may  be  increased  by 
the  occurrence  of  venous  congestion,  such,  for  instance,  as  that  which  results 
from  attempts  at  forced  expiration  with  the  mouth  and  nostrils  closed. 

Hemorrhage  from  the  Nose  and  Pharynx. — A  line  of  fracture  running 
through  the  ethmoid  bone  will  give  rise  to  hemorrhage  from  the  nasal  cavity. 
Hemorrhage  into  the  pharynx  may  have  its  origin  in  a  fracture  of  the  body  of 


438  THE  SURGERY  OF  THE  HEAD 

the  sphenoid  bone  and  rupture  of  the  mucous  meml^rane,  or  it  may  find  its 
way  into  the  pharynx  from  the  cavity  of  the  tympanum  through  the  Eustachian 
tube.  Fatal  asph}':xia  has  resulted  from  profuse  hemorrhage  in  the  latter 
situation,  the  blood  passing  down  the  air-passages  (K  o  n  i  g). 

Subconjunctival  Hemorrhage. — This  symptom  does  not  always  appear 
at  once,  and  several  da}-s  may  elapse  before  it  is  observed.  In  estimating  its 
importance  direct  injuries  to  the  palpebral  and  sclerotic  conjunctiva  must  be 
excluded.  This  symptom  is  not  so  generally  present  in  fracture  of  the  base  as 
has  been  supposed.  In  8  out  of  23  cases  it  was  absent  (Prescott 
Hewett). 

Paralysis  of  Individual  Nerves. — In  fractures  involving  the  petrous 
portion  of  the  temporal  bone  the  facial  nerve  may  be  injured  as  well  as  the 
auditory.  It  is  claimed  that  one-fourth  of  all  the  fractures  of  the  base  involves 
injury  to  these  nerves  (K  o  n  i  g).  Fractures  involving  the  semicircular  canals 
may  give  rise  to  the  vertigo  observed  in  Meniere's  disease  of  the  labyrinth ;  in 
fractures  of  the  base  this  is  usually  due  to  injury  of  the  cerebellum.  Paralysis 
of  the  motor  oculi,  trochlear  and  abducens,  either  from  pressure  resulting  from 
hemorrhage  or  from  contusion,  is  rather  rare;  strabismus,  double  vision,  etc., 
are  characteristic  symptoms  of  paralysis  of  these  nerves.  Visual  disturbances 
resulting  from  fractures  crossing  the  optic  foramen,  and  contusion  of  the  optic 
nerve  or  hemorrhage  within  its  sheath,  are  also  observed.  It  not  infrequently 
happens  that  not  more  than  one  or  two  of  these  symptoms  of  fracture  are 
present  in  a  single  case.  Very  rarely  in  cases  of  extensive  fracture  at  the  base 
all  of  them  may  be  observed. 

Traumatic  Cranial  Hydrocele  or  Pseudomeningocele. — Compound 
fractures  of  the  loAver  portions  of  the  frontal  bone  sometimes  give  rise  to  the 
escape  of  cerebrospinal  fluid  in  considerable  quantities.  In  children  in  whom 
there  exists  a  high  degree  of  intracranial  pressure  as  well  as  a  large  relative 
amount  of  cerebrospmal  fluid,  the  latter  may  escape  from  fractures  in  the 
locality  just  indicated,  without  external  wound.  This  fluid  collecting  thus 
beneath  the  scalp  constitutes  the  so-called  cranial  hydrocele  or  pseudomeningo- 
cele. Pulsation  may  be  present  in  the  tumor,  and  the  latter  has  been  sho^\Ti 
to  be  connected  directly  with  the  lateral  ventricle.  Any  attempt  to  open 
these  coUections  of  cerebrospinal  fluid  should  be  accompanied  by  the  most 
rigid  asepsis. 

Cerebral  Complications  in  Injuries  of  the  Skull.— Concussion  of  the 
brain  may  occur  without  fracture  of  the  skull,  or  even  marked  contusion. 
Considerable  disturbances  of  function  follow.  The  symptoms  consist  of  loss 
of  consciousness,  either  partial  or  complete;  paflor;  small,  feeble,  and  slow 
pulse;  vomiting.  The  condition  is  to  be  considered  as  a  temporary  inhibition 
of  the  brain  centers,  mechanically  produced.  H.Fischer  suggests  that  the 
symptoms  are  the  result  of  a  reflex  paralysis  of  the  heart  and  vessels,  in  which 
the  cerebral  vessels  likewise  share.  Stromeyer  believed  the  condition 
to  be  simply  one  of  cerebral  anemia,  arising  from  compression  of  the  skull  forcing 
the  blood  from  the  brain.  The  forcing  of  the  cerebrospinal  fluid  through  the 
aqueduct  of  Sylvius  and  against  the  floor  of  the  fourth  ventricle  has  also  been 
suggested  to  account  for  the  symptoms  (D  u  r  e  t).  The  duration  of  the  symp- 
toms varies  with  the  severity  of  the  injury.  Vomiting  occurs  but  once,  as  a 
rule.     Consciousness  generally  returns  shortly  after  the  occurrence  of  vomiting, 


THE    CRANIAL    BONES  439 

but  it  may  be  delayed  for  several  hours;  exceptionally,  days  may  elapse  before 
it  is  entirely  restored.  It  is  probable,  in  those  exceptional  cases  in  which  the 
return  to  consciousness  is  delayed  beyond  a  few  hours,  that  punctated  hemor- 
rhages have  occurred.  The  vasomotor  disturbances,  the  pallor,  and  the  small, 
weak,  and  slow  pulse  disappear  in  a  short  time  and  are  followed  by  a  directly 
reverse  condition;  the  face  becomes  reddened  and  hot  and  the  pulse  fidl  and 
strong.  This  is  called  the  stage  of  reaction.  Diabetes  mellitus,  diabetes 
insipidus,  polyuria,  and  albuminuria  have  been  observed  as  sequels  of  con- 
cussion of  the  brain.  The  explanation  of  the  phenomena  that  has  been 
hitherto  offered  has  not  proved  satisfactory.  Claude  Bernard's  well- 
known  experiments  in  the  production  of  glucosuria  by  irritation  of  the  floor 
of  the  fourth  ventricle  form  the  basis  of  the  most  plausible  theory  for  their 
occurrence. 

Compression  of  the  Brain. — The  chief  causes  usually  assigned  in  the  pro- 
duction of  compression  of  the  brain  following  injury  are:  (1)  effusion  of  fluid 
within  the  cranial  cavity ;  (2)  pressure  from  without  b}'  displaced  bone.  The 
former  is  the  more  important,  though  it  is  not  always  easy  to  separate 
the  symptoms  of  compression  from  those  of  concussion  in  cases  in  which 
considerable  contusion  occurs  at  the  site  of  the  depressed  bone.  Simple 
depression  of  the  cranial  bones  in  the  limited  area  in  which  it  is  usually  met  is 
quite  unlikely  to  give  rise  to  the  grave  symptoms  which  so  commonly  occur 
in  compression,  unless  the  brain  itself  has  been  injured.  The  symptoms  which 
occur  are  believed  to  be  due  to  the  recession  of  the  cerebrospinal  fluid  from  the 
space  which  it  occupies  between  the  arachnoid  and  the  pia  mater  in  the  interval 
between  the  two  hemispheres  at  the  base  of  the  brain,  into  the  general  ventricu- 
lar cavity  by  the  opening  of  the  inferior  boundary  of  the  fourth  ventricle,  and 
into  the  spinal  subarachnoidean  space  as  well  (B  e  r  g  m  a  n  n  and  A  1  - 
t  h  a  n  n) .  The  effect  of  this  recession  is  to  remove  the  mechanic  support 
given  by  the  cerebrospinal  fluid  to  the  nervous  centers  at  the  base  where  the 
large  vessels  of  the  brain  enter,  and  to  permit  direct  systolic  impressions  on 
the  cerebral  mass.  If  this  recession  is  sufficient  to  fill  the  connective-tissue 
spaces  ^^ithin  the  sheaths  of  the  nerves,  lymph-vessels,  and  veins  with  which 
the  subarachnoidean  space  communicates,  the  essential  symptoms  of  cerebral 
anemia  are  present  (Bergman  n) . 

According  to  K  o  c  h  e  r  ,  when  the  circulation  of  the  brain  is  interfered 
with  by  an  increase  of  intracranial  tension  a  compensatory  rise  of  blood-pressure 
takes  place,  this  equaling  or  slightly  exceeding  the  extravascular  pressure  com- 
pressing the  cerebral  vessels.  In  case  the  latter  exceeds  the  compensatory  rise 
a  fatal  bulbar  anemia  ensues.  K  o  c  h  e  r  divides  the  clmical  phenomena  of 
cerebral  compression  into  the  following  stages:  (1)  The  stage  in  which  there  is 
but  slight  encroachment  on  the  intracranial  space  and  compensation  is  accom- 
plished by  displacement  of  cerebrospinal  fluid,  and  possibly  by  changes  in  the 
lumina  of  the  venous  channels.  In  this  stage  the  symptoms  are  comparatively 
slight.  (2)  The  stage  in  which  there  is  an  obstruction  to  the  return  circulation,  in 
which  choked  disk  and  the  phenomena  of  cerebral  irritation  (headache,  vertigo, 
restlessness,  delirium,  etc.)  occur.  (3)  The  stage  in  which  the  extravascular 
compression  is  so  great  as  to  give  rise  to  functional  disturbances  through  the 
anemia  of  the  brain  which  results.  This  anemia  may  be  general  or  local,  ac- 
cording to  the  extent  of  area  of  the  brain  involved  in  the  compression,  the  symp- 


440  THE  SURGERY  OF  THE  HEAD 

toms  varying  accordingly.  In  cases  in  \\liich  the  compression  is  extensive, 
with  involvement  of  the  medulla,  symptoms  of  general  compression  supervene. 
It  is  in  this  stage  that  a  reflex  stinnilation  of  the  vasomotor  center  and  a  com- 
pensatory rise  of  blood-pressure  occur,  the  effect  of  which  is  to  balance  the  intra- 
cranial tension  and  restore  the  ecjuilibrium  between  the  extra  vascular  pressure 
of  the  cerebral  vessels  and  their  intravascular  pressure.  I'pon  the  extent  to 
which  this  is  accomplished  will  depend  the  restoration  and  maintenance  of  the 
cerebral  circulation.  As  the  conditions  present  in  the  second  stage  alternate 
from  time  to  time  with  those  of  the  third  stage,  the  symptoms  will  vary  ac- 
cordingly, such  as  alterations  in  the  size  of  the  pupils,  rhythmic  respiratory 
disturbances  (Cheyne-Stokes  respiration),  and  varying  degrees  of  cerebral 
irritation  and  stupor.  (4)  The  stage  in  which  the  characteristic  features  are 
failure  of  compensation  of  the  uitracranial  tension,  rapid  fall  in  the  blood- 
pressure,  and  a  condition  of  continuous  cerebral  anemia,  with  consecjuent 
inhibition  of  the  functions  of  the  cerebral  organs. 

In  all  cases  of  injury  of  the  head  the  blood-pressure  should  be  carefullj^ 
estimated  from  time  to  time,  and  the  knowledge  thus  obtained  made  use  of, 
particularly  in  cases  in  which  other  evidence  is  not  available,  in  determming  the 
advisability  of  operative  mterference  to  relieve  compression. 

For  comi^ression  resultmg  from  the  presence  of  pus,  see  Cerebral  Abscess, 
page  460. 

Hemorrhage  into  the  cranial  cavity  is  to  be  considered  as  almost  the  sole 
cause  of  cerebral  compression.  Further,  in  the  great  majority  of  cases  of 
hemorrhage  from  head  injuries  the  source  of  the  hemorrhage  has  its  origin  in 
one  or  more  branches  of  the  middle  meningeal  artery.  The  anterior  or  large 
branch  is  the  most  frequently  involved.  Prescott  Hewett  found  that 
among  31  cases  of  intracranial  hemorrhage  from  injury,  the  extravasation  being 
between  the  dura  and  the  bone,  in  27  the  origin  of  the  hemorrhage  Avas  the 
anterior  branch  of  the  middle  meningeal.  It  crosses  the  great  wing  of  the 
sphenoid  and  passes  to  the  groove  or  canal  at  the  anterior  inferior  angle  of  the 
parietal  bone  before  givmg  off  any  branches;  at  this  jDoint  it  is  most  easily 
reached  for  purposes  of  ligation. 

Fracture  need  not  necessarily  occur  m  order  that  rupture  of  the  vessel  may 
take  place.  Simple  and  temporarj'^  compression  of  the  cranial  bones,  the  latter 
returnmg  to  their  normal  shape  after  the  removal  of  the  force,  suffices  to  rupture 
the  vessel.  Usually,  however,  the  vessel  is  ruptured  by  a  fissure  crossing  its 
track.  This  is  favored  by  its  close  and  unyielding  attachment  to  the  dura ; 
the  latter  circumstance  is  also  an  important  factor  in  preventmg  the  spon- 
taneous arrest  of  hemorrhage. 

Hemorrhage  from  other  intracranial  vessels  is  also  observed,  though  rarely. 
The  internal  carotid  may  be  torn  across  its  track  by  a  fracture  as  it  passes 
through  the  petrous  portion  of  the  temporal  bone.  The  basilar  artery  has  been 
known  to  be  involved  in  a  fracture  of  the  occipital  bone.  (For  special  varieties 
of  intracranial  hemorrhage  see  page  456.) 

The  rapidity  with  which  symptoms  of  compression  supervene  after  the 
occurrence  of  the  injury  will  depend  on  (1)  the  size  of  the  vessel  injured;  (2) 
the  force  of  the  circulation ;  (3)  whether  or  not  the  extravasated  blood  escapes 
from  the  cranial  cavity.  This  sometimes  forces  its  w^ay  through  the  fissure, 
and  in  the  case  of  a  simple  fracture  effuses  itself  beneath  the  scalp  and  there 


THE    CRANIAL    BONES  441 

forms  a  large  coagulum.  If  the  fracture  is  c()nii)licated  by  a  wound  of  the  scalp 
the  blood  may  escape  externally.  These  conditions  will  delay  and  perhaps 
prevent  altogether  the  occurrence  of  symptoms  of  compression.  Though,  as  a 
rule,  the  latter  are  quite  distinctive  within  a  few  hours,  in  rare  instances  several 
days  elapse  before  they  develop  sufficiently  to  warrant  interference. 

The  pressure,  as  a  rule,  involves  but  one  hemisphere.  Occasionalh',  how- 
ever, the  blood  finds  its  way  from  one  parietal  region  to  the  other,  forming  a 
semicircular  broad  band  of  coagulum  across  the  vertex.  When  but  one  hemi- 
sphere is  involved  in  the  pressure,  a  paralysis  of  the  upper  and  lower  extremity 
of  the  opposite  side  is  manifest,  which  may  be  preceded  by  a  short  stage  of 
involuntarv  nmscular  twitching;  true  convulsions  may  occur.  The  pulse  is 
almost  invariablv  diminished  in  frequency,  being  sometimes  as  low  as  40  beats 
to  the  minute  or  lower;  this  is  one  of  the  most  constant  symptoms  and  seems 
to  bear  no  particular  relation  to  the  part  affected  by  the  compression.  The 
sensorium  now  suffers  in  a  most  decided  manner;  unconsciousness  slowly 
supervenes  until  coma  develops.  Finally  the  respirations  grow  less  and  less 
frequent  and  life  is  gradually  extinguished. 

The  differential  diagnosis  of  concussion  of  the  brain  and  compres- 
sion of  the  brain  offers  no  special  difficulties.  In  the  case  of  the  former 
the  manner  of  invasion  is  sudden,  while  in  the  case  of  the  latter  it  is  a  com- 
parativelv  slow  process.  In  concussion  the  pulse,  though  it  may  become 
slow,  is  likewise  feeble,  while  in  compression  the  lessened  pulse-rate  is  not 
marked  bv  a  corresponding  diminution  of  force.  In  concussion  the  pallor  of 
the  surface  is  marked,  while  in  compression  the  natural  color  is  maintained. 
The  respiratory  act  is  not  affected  in  concussion,  while  in  compression  the  vagus 
center  is  affected  most  decidedly.  In  concussion  the  pupils  generally  respond 
to  light,  though  thev  mav  be  unevenly  contracted,  while  in  compression  they 
are  fixed,  usually  dilated,  and  do  not  respond  to  light.  The  only  symptom 
common  to  the  two  conditions  is  that  of  unconsciousness,  and  the  manner  m 
which  this  occurs  differs  so  greatly  that  there  is  scarcely  room  for  error  when  a 
proper  historv  of  the  case  can  be  obtained. 

Hemorrhages  from  the  Sinuses  of  the  Dura  Mater.— These  large  venous 
channels  mav  be  injured  and  yet  the  patient  may  recover.  Schell- 
m  a  n  n  '  s  experiments  on  dogs  show  that  but  slight  pressure  is  necessary  to 
restrain  hemorrhage  from  this  source.  Fatal  hemorrhage  from  the  transverse 
and  cavernous  sinuses  has  occurred,  however.  In  extreme  anemia  of  the  brain 
together  with  marked  diminution  of  the  cardiac  impulse  aspiration  of  air  may 
occur,  when,  for  instance,  the  longitudinal  sinus  is  opened  and  exposed.  Hem- 
orrhage from  the  superior  longitudinal  sinus  in  fracture  of  the  vertex,  and  from 
the  lateral  sinuses  in  fractures  of  the  occipital  bone,  may  be  held  in  check  by 
the  presence  of  depressed  bone.  On  the  elevation  of  the  depressed  portion  the 
hemorrhage  will  appear  at  the  opening,  lender  these  circumstances,  rapid 
removal  of  the  fragment  and  the  prompt  application  of  a  clamp  or  hemostatic 
forceps  is  indicated.  In  making  forcipressure,  one  blade  of  the  clamp  passes 
within  the  cranial  cavity  and  forces  the  bleeding  sinus  against  the  inner  surface 
of  the  bone,  while  the  other  blade  rests  on  the  outer  surface  of  the  bone.  Should 
the  size  of  the  opening  preclude  this  procedure,  the  opening  should  be  rapidly 
enlarged.  The  finger  passed  through  the  opening  in  the  skull  will  of  itself  hold 
the  bteeding  in  check,  while  by  means  of  K  e  e  n  '  s  gouge  forceps  (see  Fig.  91) 


442  THE  SURGERY  OF  THE  HEAD 

this  opening  is  enlarged  and  the  opening  in  the  dura  is  also  increased  in  size,  if 
necessary,  with  the  scissors.  The  clamp,  once  satisfactorily  in  position,  should 
not  be  disturbed  for  from  twenty-four  to  forty-eight  hours.  An  excellent 
and  expeditious  method  of  stopping  hemorrhage  from  a  bleeding  sinus  is  to 
make  firm  pressure  in  the  wound  b>'  ])acking  with  compresses  of  iodoform 
gauze. 

Contusion  and  Laceration  of  the  Brain. — These  are  not  infrequent 
accompaniments  of  injuries  of  the  cranial  bones  and  are  to  be  classed  with  the 
most  important  of  the  complications  of  these  lesions  (see  page  455).  In  cases 
in  which  compound  fracture  with  depression  occurs  to  an  extent  sufficient  to 
permit  brain  matter  to  escape,  the  latter  exudes  as  a  pulpy  mass  more  or  less 
mixed  with  blood. 

Clinical  Course  of  Simple  Fractures  of  the  Skull. — Uncomplicated 
fractures  of  the  skull  pursue  the  same  uneventful  course  as  simple  fractures 
elsewhere.  A  noticeable  feature  is  the  small  amount  of  callus  produced 
during  the  processes  of  repair.  This  is  to  be  ascribed  to  the  immobility 
of  the  fragments  and  the  consequent  very  slight  irritation  present.  This  also 
explains  the  absence,  as  a  rule,  of  symptoms  of  cerebral  irritation  such 
as  would  follow  the  presence  of  deposits  of  new  bone  on  the  inner  sur- 
face of  the  cranial  bones.  Cases  occur,  however,  in  which  disturbances 
of  function  result  from  the  formation  of  bony  deposits  in  this  location; 
operative  procedures  are  necessary  for  the  relief  of  these.  Complete  regenera- 
tion following  losses  of  bone,  either  from  accidental  mjury  or  from  the  use  of 
the  trephine,  almost  never  occurs.  The  dura  mater  here  assumes  the  function 
of  a  periosteum,  though  but  to  a  minor  extent,  as  shown  by  the  fact  that 
excessive  formation  of  callus  under  these  circumstances  is  almost  unknown. 

In  simple  uncomplicated  fractures  of  the  cranium  repair  takes  place  Avithout 
any  treatment  other  than  the  protection  afforded  by  the  unbroken  scalp. 
Minor  disturbances  of  the  cerebral  tissue  likewise  require  no  further  care  aside 
from  that  embraced  in  the  expectant  plan.  Should  symptoms  of  concussion 
persist,  however,  beyond  those  of  a  simple  and  temporary  "stun,"  stimulating 
treatment  should  be  instituted,  such  as  application  of  artificial  heat,  the 
administration  of  hot  alcoholic  drmks  m  small  quantities,  by  the  mouth  if  the 
patient  can  swallow,  otherwise  through  the  rectum.  Hypodermic  injections  of 
camphorated  ether,  inhalations  of  aqua  ammoniae  to  stimulate  the  heart,  and 
shiapisms  to  the  surface  of  the  extremities  are  also  useful.  The  hypodermic 
injection  of  yto  ^^  ^  grain  of  sulfate  of  atropm  to  increase  the  arterial  pressure, 
and  inhalations  of  nitrite  of  amyl  to  lessen  the  resistance  to  the  passage  of 
blood  through  the  smaller  vessels  and  capillaries,  are  also  useful.  Under  no 
circumstances  should  ice  or  cold  water  be  applied  to  the  head  during  this  stage. 
As  soon  as  reaction  is  established  all  stimulating  measures  should  be  aban- 
doned; with  excessive  reaction  a  new  line  of  treatment  is  indicated.  Fuhness 
of  the  cerebral  vessels,  as  indicated  by  the  flushed  face,  congestion  of  the 
conjunctiva,  and  throbbing  of  the  temporals,  is  to  be  met  by  the  application  of 
the  ice-cap  or  ice-cold  compresses.  At  the  same  time,  the  administration  of  an 
active  cathartic,  such  as  a  powder  containing  10  grains  of  powdered  jalap,  is  a 
useful  adjunct  to  the  local  treatment. 

The  treatment  of  compression  of  the  brain  \Yi\\  depend  on  its  causes.  If 
due  to  clot,  this  should  be  turned  out  and  the  bleeding  vessel  tied  if  necessary. 


Tin:    CKA.XIAL    BOXKS  443 

If  tlie  result  of  abscess,  this  should  be  evacuated.  The  cause  being  removed, 
the  brain  usually  recovers  its  functions.  As  a  rule,  ligation  of  the  vessel  after 
remo^■al  of  the  coagulum  is  not  necessary;  the  hemorrhage  will  be  found  to  have 
ceased.  Should  it  persist,  however,  removal  of  a  sufficient  amount  of  bone  to 
enable  the  vessel  to  be  reached  will  be  indicated,  and  may  be  effected  in  a  rapid 
and  satisfactory  manner  liy  means  of  Keen  '  s  gouge  forceps  (Fig.  91). 

Clinical  Course  of  Compound  Fractures  of  the  Skull. — In  the  absence 
of  infection,  union  of  a  fracture  of  the  skull  complicated  by  an  external  wound 
progresses  m  all  essential  particulars  precisely  as  union  of  a  simple  fracture. 
This  is  particularly  true  if  primary'  union  of  the  soft  parts  takes  place.  WTiere 
union  by  secondar}'  intention  occurs,  the  reparati^'e  process  goes  on  rapidly  and 
cicatrization  is  soon  accomplished.  The  occurrence  of  septic  infection,  how- 
ever, exposes  the  patient  to  grave  special  dangers,  such  as  erysipelas  and 
phlegmonous  inflammation,  which  may  lead  to  meningeal  and  cerebral  compli- 
cations. Suppurative  osteomyelitis  of  the  diploe  and  general  pyemic  itifection 
may  also  follow. 

It  was  formerly  thought  that  fractures  of  the  skull  gave  rise  to  a  special 
danger  from  metastatic  abscesses.  It  has  been  sho^Aii,  however,  that  there  is  no 
greater  tendency  to  this  complication  in  these  fractures  than  in  injuries  else- 
where. 

Pachymeningitis. — The  dura  mater  is  not  readily  disposed  to  inflamma- 
tion, owmg  to  its  structure.  Hence  inflammation  of  this  membrane  is  not  a 
common  result  of  head  injuries;  when  it  does  occur,  it  is  usually  hmited  to  the 
place  of  mjury.  Suppuration  between  the  dura  and  the  internal  surface  of  the 
skull,  however,  as  well  as  between  the  peri  cranium  and  the  external  surface,  leads 
to  necrosis;  this  occurs  the  more  readily  when  considerable  splintering  takes 
place.  This  suppurative  process  becomes  the  more  dangerous  from  the  ten- 
dency to  septic  phlebitis  and  thrombosis  of  the  vems  communicating  through 
the  dura  with  those  of  the  pia  mater,  arachnoid,  and  encephalon.  In  the  case  of 
the  first  named,  a  leptomeningitis  develops  (see  page  458).  Though  the 
manner  of  mfection  described  is  m  aU  probabilit}'  the  most  common,  it  is  not 
to  be  denied  that  suppurative  mflammation  of  both  the  external  and  the  internal 
surface  of  the  dura  may  occur,  infection  of  the  arachnoid  and  pia  mater  and 
consequent  leptomeningitis  arismg  from  contact  through  the  lymph  and  blood- 
vessels. The  vascularity  of  the  last-named  membranes  tends  to  rapid  spread 
of  inflammation.  Er\'sipelas  may  affect  the  arachnoid  and  pia  mater  through 
the  medium  of  the  lymph-channels  or  blood-vessels.  Again,  infection  may 
occur  from  the  foreign  body  which  produces  the  mjury.  or  from  portions  of  head 
covering  or  from  the  hair  itself  (see  Traumatic  Menmgitis.  page  457).  Suppu- 
rative meningitis  is  to  be  considered  an  absolutely  fatal  affection. 

Treatment  of  Compound  Fractures  of  the  Skull. — The  first  care  of  the 
surgeon  should  be  to  protect  the  wound  itself  ^^ith  a  gauze  compress  AATimg  out 
of  1  :  1000  mercuric  chlorid  solution  of  sufficient  size  to  fill  the  wound  com- 
pletely. Next  the  entire  scalp  must  be  shaved  and  cleansed,  first  with  soap  and 
Avater  followed  by  alcohol,  and  subsecjuently  A^ith  ether:  lastly  -^ith  a  1  :  2000 
mercuric  chlorid  solution  m  50  per  cent  alcohol.  The  wound  itself  is  now  to  be 
cleared  thoroughly  of  all  macroscopic  dirt  and  disinfected  Anth  the  above 
mentioned  mercuric  chlorid  solution.  Stress  is  here  laid  on  these  precautions, 
though  they  are  described  elsewhere,  their  importance  being  enhanced  hi  this 


444 


THE    SURGERY    OF   THE    HEAD 


connection  by  the  .e;rave  complications  which  follow  failure  to  exercise  from 
the  very  beghming  the  greatest  possible  care  in  the  treatment  of  this  class 
of  injuries.  The  wound  should  be  sufficiently  enlarged  to  permit  proper 
exploration  and  the  removal  of  foreign  bodies.  Ocular  inspection  should  be 
practised.  It  is  not  sufficient  to  ascertain  that  a  simple  fissure  exists;  hair  is 
sometimes  imprisoned  in  the  latter  and  must  be  removed.  A  knife-blade  or 
other  pointed  instrument  may  have  been  driven  through  the  skull  and  broken 
off  below  the  level  of  the  bone. 

The  further  operative  procedure  will  be  guided  by  the  condition  found  on 
exploration.  If  blood  oozes  in  considerable  quantities  from  the  fissure,  the 
cavity  of  the  skull  is  to  be  entered  by  removal  of  sufficient  bone  for  the  purpose. 


Fig.  238. — Application  oi   Chisel  and  Mallet  to  the  Skull  in  Depressed  Fracture. 
The  skull  is  exposed  through  an  "X"  incision.     The  dotted  lines  are  intended  to  show  the  method 
ot  making  a  large  opening  in  the  skull  when  this  is  required  for  purposes  other  than  the  removal  of  the 
iragments  in  depres.'sed  fracture. 

Fragments  of  bone  detached  from  the  pericranium  and  dura  are  to  be  removed. 
Although  the  importance  of  depressed  portions  of  bone  in  producing  symptoms, 
of  compression  has  been  very  much  overestimated,  they  should  nevertheless  be 
brought  up  to  their  proper  level,  for  the  reason  that  foreign  bodies,  hair,  as  well 
as  loose  spiculas  of  bone,  may  have  been  carried  do\\Ti  with  the  edge  of  the 
depressed  bone.     Drainage  of  the  parts  is  also  thus  greatly  facilitated. 

A  time-saving  method  of  elevating  the  fragments  consists  in  chiseling  away 
v^dth  a  chisel  and  mallet  (Fig.  238)  a  portion  of  the  undepressed  bone  at  the 
margin  of  the  depressed  portion  to  an  extent  sufficient  to  permit  introduction  of 
the  elevator  (Fig.  239) .  With  the  back  of  the  latter  resting  on  the  solid  edge 
of  the  intact  bone  and  its  point  beneath  the  fragment,  a  powerful  lever  is  formed 


THE    f'RAXIAL    BOXES 


445 


and  the  depressed  bone  is  lifted  into  position  (I'ig.  240).  It  will  rarely  be  neces- 
sary to  remove  fraji'nients  permanently  in  cases  in  Avhich  an  asejitic  course  is 
expect chI;  e\-en  wlum  these  are  lilt(>(l  away  for  purposes  of  thoroup;h  cleansing, 
they  may  be  frequently  replaced  with  advantage  (Oilier,  Mace  wen). 
When  the  uijury  to  the  cranial  bones  is  quite  extensive,  and  particularly  when 
the  wound  has  been  exposed  to  possible  infection  for  a  long  time  before  coming 


Fig.  239. — Elevator  for  Elevating  Fragmexts  in  Fracture  of  the  Vault  of  the  Skull. 

nnder  the  surgeon's  care,  the  fragments,  if  detached  completely,  may  be 
removed.  It  will  scarcely  ever  be  necessary  to  employ  the  trephine  in  cases  of 
depressed  fracture.  The  chisel  and  mallet,  if  properly  employed,  will  always 
fulfil  all  the  indications  with  less  destruction  of  bony  tissue  and  considerable 
saving  of  time. 

Even  fissures  are  to  be  treated  operatively  in  order  that  the  best  results 


Fig.  240. — Elevation  of  Fragments. 


may  be  obtained.  The  beveled  edge  of  the  chisel  is  applied  toward  the  surface 
of  the  skull  and  held  in  such  a  manner  that  the  corner  of  the  chisel  cuts  away 
the  edge  of  the  fissure  at  an  angle.  By  cutting  away  both  edges  in  this  manner 
a  V-shaped  groove  is  formed  which  enters  the  diploe.  Drainage  of  the  latter 
is  thus  provided  for.  and  all  foreign  bodies,  hair,  etc.,  which  may  have  entered 
when  the  fissure  gaped  Avidely  are  thoroughly  removed.     The  V-shaped  gouge 


446 


THE    SURGERY    OF    THE    HEAD 


may  be  advantageously  employed  for  this  purpose.  Projecting  edges  of  bone 
which  prevent  elevation  of  the  fragments  ma}'  also  be  chiseled  away  with 
advantage. 

The  operative  procedure  being  completed,  the  wound  itself  claims  attention. 
This  should  be  treated  on  general  antiseptic  principles  if  infection  has  occurred. 
The  use  of  an  antiseptic  irrigating  fluid  is  rather  to  be  deprecated  and  is  con- 
traindicated  if  there  exists  a  wound  of  the  dura.  If  it  is  employed  it  should 
be  subsequently  washed  away  with  a  sterilized  salt  solution.  In  place  of  the 
irrigating  fluid,  gauze  sponges  wrung  out  of  a  1  :  1000  mercuric  chlorid  solution, 
a  2.5  to  5  per  cent  solution  of  carbolic  acid,  or  a  5  per  cent  solution  of  zinc  chlorid 
may  be  employed,  if  decided  septic  conditions  are  already  present.     In  case  of 


Fig.  241. — Removing  a  Portion  of  the  Skull  with  the  Gigli  Wire  Saw. 

injury  of  the  brain  substance,  the  last  named  is  considered  to  be  particularly 
efficacious  (Socin).  The  question  of  drainage  is  an  important  one.  The 
ideal  method  is  to  close  the  wound  completely,  but  this  presupposes  an  aseptic 
condition  of  the  parts,  of  which  the  surgeon  cannot  always  be  certain.  The 
gauze  drain  a^tII  fulfil  all  the  indications,  if  the  simple  leaving  open  of  the  most 
dependent  portions  of  the  wound  is  not  deemed  sufficient.  If  all  goes  well  and 
no  drain  has  been  employed,  the  wound  need  not  be  disturbed  for  a  week  or  ten 
days.  If  a  drain  has  been  introduced,  this  should  not  remain  longer  than 
twenty-four  or  thirty-six  hours,  at  the  end  of  which  time,  in  the  great  majority 
of  cases,  the  wound  after  being  redressed  may  remain  undisturbed  for  the  period 
of  time  occupied  by  the  healing  process. 


THE   CRANIAL    BONES 


447 


In  fractures  at  the  base  purely  surgical  measures  are  restricted  to  those 
which  proA'ide  ai2;ainst  infection  through  the  nasal  cavit}'  m  fractures  of  the 
anterior  fossa,  and  through  the  auditory  canal  m  case  there  is  escape  of  cerebro- 
spinal fluid,  hi  fractures  of  the  middle  fossa.  The  external  auditory  canal  is 
cleansed  with  soap  and  water  and  a  cotton  probe,  thoroughly  washed  (not 
forcibly-  irrigated)  with  an  antiseptic  solution  (the  borosalicylic  solution  of 
Thiersch),  and  lightly  packed  \\ith  cotton  or  gauze  wrung  out  of  a  mercuric 
chlorid  or  carbolic  acid  solution.  The  nasal  cavity  is  not  so  readily  protected. 
This  should  be  washed  out  with  a  boric  acid  solution  and  the  anterior  nares 
lightly  packed.  Pluggmg  the  posterior  nares  pro- 
duces considerable  irritation  and  increased  flow  of 
mucus,  which  latter  offers  a  still  greater  opportun- 
ity for  putrefactive  changes  and  hence  sepsis. 

In  addition  to  these  measures  the  patient  is  to 
be  placed  under  conditions  which  shall  insure  the 
greatest  possible  Ciuietude,  and  the  ice-cap  applied. 
The  administration  of  a  calomel  and  jalap  purge 
and  the  subsequent  administration  of  remedies  to 
control  pain,  etc.,  are  indicated.  The  bromids  may 
be  tried;  the  use  of  opium  is  not  contraindicated 
and  in  some  cases  is  useful.  In  extreme  restless- 
ness and  delirium  doses  of  y-^o  of  a  grain  of  hydro- 
bromate  of  hyoscin  given  hypodermicalh'  will  be 
found  useful. 

Trephining. — The  application  of  the  trephine  is 
not  so  frequently  required  m  fractures  of  the  skull 
as  heretofore,  its  place  being  supplanted  by  the 
mallet  and  chisel  (Fig.  238)  and  the  Luer  or 
Keen  gouge  forceps  (Fig.  91).  In  traumatic 
epilepsy  and  in  brain  tumors  and  brain  abscesses 
the  trephine  is  useful  in  making  the  first  perfora- 
tion in  exploratory  operations. 

The  method  of  drilling  holes  at  proper  dis- 
tances and  dividing  the  intervening  spaces  with 
the  G  i  g  1  i  wire  saw  also  has  its  advocates  (Fig. 
241).  The  incisions  necessary"  to  bare  the  sur- 
face of  the  skull  in  nontraumatic  cases  should  be 
U-shaped,  the  base  of  the  flap  being  preferably 
toward  the  base  line  of  the  skull.  In  cases  of  frac- 
ture of  the  vault  an  X-shaped  incision  is  employed 
in   order  to   permit   extension  of  the  incisions  in 

all  directions  in  following  up  lines  of  depressed  fractures  (Fig.  238).  The 
pericranium  should  be  lifted  with  the  flap  by  means  of  the  periosteal  elevator 
(Fig.  239).  Either  Gait's  conical  trephine  (Fig.  85),  the  aseptic  hand  trephine 
(Roberts,  Fig.  84),  or  the  aseptic  brace  trephine  (Fig.  242)  may  be 
employed.  The  latter  with  its  guard  rings  insures  rapid  and  safe  perforation 
of  the  cranial  cavity.  The  method  of  its  application  is  readily  shown  in 
the  figure.  Several  widths  of  guard  rings  are  furnished  (Fig.  242.  D).  The 
widest  of  these,  which  permits  the  crown  of  the  instrument  to  make  a  simple 


Fig.  242. — The  Aseptic  Brace 
Trephine. 
A  A,  Brace;  B  B,  handles; 
C,  pin  detached ;  C,  upper  sur- 
face of  pin  showing  clutch;  D, 
guard  rings  detached;  E,  crowTi, 
with  guard  ring  in  position;  F, 
stem. 


448  THE  SURGERY  OF  THE  HEAD 

groove,  is  first  employed.  This,  together  with  the  pin,  which  up  to  this  time 
has  served  as  an  axis  on  which  the  crown  rotates  (Fig.  242,  C),  is  removed, 
and  a  narrower  ring  permitting  a  still  deeper  groove  is  substituted.  A  turn 
or  two  of  the  brace  suffices  to  bring  the  trephine  to  the  full  depth  permitted 
by  the  guard  ring.  As  the  operator  has  no  fear  of  unexpectedly  perforating 
the  cranial  cavity,  these  movements  ma}"  be  executed  boldly  and  rapidh*. 
The  guard  rings  are  changed  in  a  few  seconds  and  the  operator  has  the  satis- 
faction of  knowing,  first,  the  exact  depth  which  has  been  reached;  and, 
second,  that  the  groove  is  the  same  depth  in  its  whole  extent — advantages 
which  give  him  greater  confidence  in  his  manipulation.  The  awkward  and 
strained  movements  which  involve  considerable  muscular  exertion,  as  in 
the  use  of  the  hand  trephine,  are  avoided.  Each  time  the  guard  ring  is  changed 
for  a  narrower  one,  the  button  of  bone  is  tapped  with  the  handle  of  a  scalpel 
or  the  elevator  to  ascertain  if  it  is  yet  loosened. 

Osteoplastic  resection  of  quadrangular  plates  of  bone  (J.  Wolf  f),  though 
an  ideal  procedure,  is  difficult  in  its  technic.  Three  sides  of  the  square  are 
grooved  to  the  entire  thickness  of  the  bone  by  a  narrow  chisel,  the  scalp  not 
being  turned  back,  but  simply  incised,  and  the  grooves  cut  at  the  bottom  of  the 
openings  made  by  the  incisions,  the  edges  of  the  latter  being  retracted  for  the 
purpose.  The  fourth  side  of  the  cjuadrangle  is  broken  across  by  prying  up  the 
piece;  it,  together  with  the  flap  of  the  scalp  which  remains  attached  to  it,  is 
raised  up  like  a  trap-door.  The  same  procedure,  with  an  omega-shaped  flap 
of  scalp  and  bone  (W  a  g  n  e  r) ,  permits  a  more  ready  fracture  of  the  base  of  the 
bony  portion  of  the  flap,  the  latter  being  narrower  in  proportion  to  the  area  of 
the  remainder  of  the  flap. 

Indications  for  Trephining. — In  addition  to  enlarging  openings  in  the  skull 
to  facilitate  the  elevation  of  depressed  portions  of  bone  and  the  removal  of 
fragments  (which,  as  before  stated,  is  best  accomplished  by  chiseling),  it 
becomes  necessary  to  trephine  for  the  removal  of  foreign  bodies.  Many  of 
these,  however,  such  as  smooth  pieces  of  metal,  small  pistol  balls,  etc.,  remain 
in  the  cranial  cavity  without  apparent  detriment,  provided  the  patient  recovers 
from  the  first  effects  of  the  injury.  Instances  are  recorded  of  pistol  balls  that 
remained  in  the  cranial  cavity  for  years  and  w^ere  found  postmortem,  the 
patients  dying  from  diseases  having  no  connection  with  the  presence  of  the 
foreign  body  in  the  brain.  Large  bullets,  however,  and  rough  foreign  bodies  do 
harm.  In  exploring  for  these,  after  the  dura  mater  has  been  trephined  and 
incised  a  light  aluminum  probe  is  introduced  and  permitted  by  the  force 
of  gravity  to  find  its  way  along  the  supposed  bullet  track  (Fluhrer). 
Incision  of  the  brain  may  also  be  practised  for  the  purpose  of  further  explora- 
tion. The  telephone  probe  (G  i  r  d  n  e  r)  w^ill  be  found  to  be  a  useful  instru- 
ment in  locating  metallic  foreign  bodies  in  the  brain  as  elsewhere  (Fig.  64). 
The  Rontgen  ray  should  be  used  when  available. 

The  treatment  of  compression  arising  from  hemorrhage  from  the  middle 
meningeal  artery  has  already  been  dwelt  on.  In  cases  in  which  no  fracture 
occurs  and  yet  the  suspicion  exists  that  rupture  of  the  vessel  has  taken  place 
from  a  blow  on  the  side  of  the  head,  the  bone  having  from  its  elasticity  sprung 
back  to  its  normal  position  without  fracture,  trephining  and  ligation  of  the 
artery  at  the  point  where  it  passes  to  the  lateral  wall  of  the  cranial  cavity  are 
indicated.     The  anterior  branch  of  the  middle  meningeal  artery  can  be  con- 


THE    CRAXIAL    BONES  449 

veniently  located  as  follows :  Two  lines  are  drawn  at  right  angles  to  each  other. 
Tiie  one  is  vertically  placed  and  is  located  an  inch  and  a  half  in  front  of  the 
external  auditory  meatus;  the  other  is  horizontally  placed  one  inch  above  the 
edge  of  the  zygoma.  The  point  at  which  these  lines  cross  each  other  represents 
the  center  of  the  middle  meningeal  area.  In  applying  the  trephine  at  this  point 
the  extreme  thinness  of  the  bone  should  be  borne  in  mind.  A  U-shaped  flap, 
which  includes  in  its  thickness  the  skin  and  temporal  muscle,  large  enough  to 
expose  the  middle  meningeal  area,  is  turned  back  and  a  large  button  of  bone  is 
removed;  after  the  clot  is  turned  out  the  vessel  is  exposed  and  secured.  The 
opening,  if  not  already  sufficiently  large  to  enable  the  bleedmg  point  to  be 
reached,  may  be  rapidly  enlarged  by  means  of  Keen's  gouge  forceps 
(Fig.  91).  Sometimes  the  bleeding  point  can  be  identified  by  turning  back  the 
dura  by  means  of  a  spatula.  If  it  is  found  that  the  anterior  branch  is  not 
injured,  the  source  of  the  bleeding  must  be  sought  in  the  posterior  branch  by 
applying  the  trephine  over  the  parietal  prominence.  These  failing,  ligation  of 
the  external  carotid  artery  is  indicated.  In  cases  of  brain  abscess,  secondary 
trephmirig  is  indicated,  to  permit  the  evacuation  of  pus  and  drainage.  Even 
the  occurrence  of  suppurative  menmgitis  and  cortical  encephalitis  A\'ill  permit 
the  application  of  the  trephine,  smce  no  better  antiseptic  or  antiphlogistic 
measure  offers.  If  performed  sufficiently  early,  this  may  yet  prove  a  rational 
method  of  meeting  the  indications  in  these  otherwise  almost  necessarily  hope- 
less cases.  In  focal  suppurative  encephalitis  or  brain  abscess  the  diagnostic 
acumen  of  the  surgeon  is  taxed  to  the  utmost  to  determine,  first,  the  existence 
of  an  abscess,  and,  second,  its  location  (see  Cerebral  Localization,  page  466). 
The  trephine  opening  havmg  been  made  at  the  place  to  which  the  symptoms 
pointed  as  the  probable  seat  of  the  abscess,  even  after  the  use  of  the  explormg 
needle  and  syringe  no  pus  may  be  found.  The  great  mortalit}'  of  abscess  of  the 
bram.  on  the  one  hand,  and  the  fact  that  50  per  cent  recover  if  success  follows 
the  effort  to  locate  the  same,  on  the  other,  will  impel  the  surgeon  to  persist  m 
his  efforts  when  the  symptoms  are  at  all  well  marked.  The  sense  of  fluctuation 
is  not  always  available  in  this  situation ;  absence  of  pulsation,  though  suggestive, 
is  not  to  be  relied  on. 

Foreign  bodies,  producing  symptoms  of  irritation  of  the  brain,  may  recjuire 
the  operation  of  secondary  trephmmg.  Broken-off  knife-blades  have  been  thus 
removed  after  the  lapse  of  years.  The  occurrence  of  paralysis,  epilepsy,  and 
mental  disturbances  with  a  history  of  head  injury  constitutes  an  indication  for 
trephining.  The  site  of  the  injury  is  usually  selected  for  this  purpose. 
H  u  e  t  e  r  mentions  an  instance  in  which  a  paralysis  of  seven  years"  duration 
was  relieved  by  trephining  at  the  site  of  injury.  A  hyperostosis,  together  A\ith 
portions  of  lead  from  a  pistol  ball,  was  removed.  In  epilepsy  following  cranial 
injury  a  certain  small  number  of  mild  cases  are  improved  l\v  simple  excision 
of  the  cicatrix  in  the  soft  parts.  Tenderness  of  the  scar  is  usually  present  here. 
But  by  far  the  greater  number  of  cases  relieved  by  trephining  are  those  having 
depressed  portions  of  bone  and  thickening  at  the  site  of  the  injury.  The  pro- 
liferation may  not  always  be  demonstrable  until  a  button  of  bone  has  l^een 
removed.  Though  many  of  the  successes  reported  have  been  l^ut  temporary. 
3-et  the  impossibility  of  cure  b}'  other  means  fully  justifies  the  attempt  at  cure 
ly\^  operative  means,  when  a  clear  history  of  injury  can  be  obtained  (see  Surgical 
Epilepsy,  page  471). 
30 


450  THE    SURGERY    OF    THE    HEAD 


GUNSHOT  INJURIES  OF  THE  HEAD 

The  traumatism  of  the  bullet  in  this  region  differs  from  that  arising  from 
any  other  cause,  for  the  reason  that,  no  matter  how  apparently  slight  the  injury, 
the  element  of  concussion  always  enters  largely  into  the  case.  The  symp- 
toms therefore  are  those  of  concussion  (even  if  the  bullet  does  not  enter  the 
head),  followed  by  those  of  fracture,  and  finally,  in  severe  cases,  of  laceration  of 
the  brain. 

The  first  effects  of  concussion  in  gunshot  injuries  of  the  head  are  manifested 
in  the  oblongata;  the  respiratory  center  is  at  once  inhibited  or  aVjsolutely 
paralyzed.  The  physical  influence  of  the  bullet  on  the  encephalic  contents 
is  a  hydrodynamic  one  (K  r  a  m  e  r  and  H  o  r  s  1  e  y) . 

Other  centers  likewise  suffer,  their  functions  remaining  suspended  until  the 
general  effects  of  the  concussion  have  passed  off.  In  moderate  concussion  the 
heart's  action  may  be  retarded;  in  severe  concussion,  accompanied  by  lacera- 
tion of  brain  tissue,  it  will  be  accelerated  from  paralysis  of  the  vessels  and  loss 
of  vascular  tone. 

The  missile  from  a  modern  rifle  will  rarely  lodge  in  the  cranial  cavity,  but 
the  ordinary  pistol  bullet  will  often  do  so.  Where  the  bullet  enters  and  emerges 
the  wound  is  called  a  perforating  wound;  where  the  bullet  enters  but  does  not 
leave  the  cavity  of  the  skull,  it  is  called  a  penetrating  wound. 

The  secondary  symptoms  of  gunshot  injuries  of  the  head  are  of  so  varied 
a  character  as  to  be  entirely  untrustworthy  in  locating  the  bullet. 

In  conducting  the  examination  of  a  case  of  gunshot  injury  of  the  head, 
when  a  fractui'e  is  found  but  no  evidence  of  perforation  exists,  the  possibility 
of  the  bullet's  having  entered  the  cranial  cavity  between  a  depressed  fragment 
and  the  adjoining  sound  bone,  the  former  having  sprung  back  from  its  natural 
elasticity,  should  be  borne  in  mind  (B  e  r  g  m  a  n  n).  Or  a  portion  of  a  bullet 
may  pass  in  this  way,  the  remaining  portion  lodging  beneath  the  scalp  (case 
in  my  ovm  practice).  Another  fallacy  may  arise  from  a  separation  of  the  bullet 
into  two  portions,  one  portion  escaping  through  an  opening  of  exit,  the  other 
remaining.  A\Tien  the  bullet  enters  from  the  direction  of  the  cavity  of  the 
mouth  it  may  lodge  in  the  nasal  fossa  or  in  one  of  the  accessor}^  sinuses.  It 
may  glance  off  from  the  bony  structure  of  the  base  of  the  skull  at  the  back  of 
the  pharjTLX  and  finally  lodge  in  the  ca%dty  of  the  mouth.  Or.  it  may  pass 
either  into  the  esophagus  and  be  swallowed,  or  through  the  glottic  opening, 
lodging  finally  in  the  larATix,  the  trachea,  or  the  bronchus. 

In  gunshot  injuries  of  the  facial  region  the  bullet  may  pass  from  below 
through  the  accessory  sinuses  and  reach  the  cranial  cavity;  or  it  may  stop  short 
of  the  latter,  in  which  case  the  missile  may  usually  be  traced  by  the  telephone 
probe  and  its  removal  effected. 

Occasionally  a  case  is  observed  in  which  a  would-be  suicide  places  the 
muzzle  of  a  pistol  to  the  ear,  in  the  belief  that  access  to  the  cranial  cavity  is 
more  easily  effected  by  this  route.  In  a  case  of  this  kind,  during  my  service 
at  the  Methodist  Episcopal  Hospital,  an  injury  of  the  internal  carotid  artery  in 
the  carotid  canal  occurred,  the  walls  of  which  had  been  crushed  in  by  a  bullet, 
the  presence  of  the  latter,  however,  preventing  hemorrhage.  Upon  removing 
the  missile  a  violent  hemorrhage  took  place,  necessitating  ligation  of  the 
common  carotid  arterv. 


THE    CKAXIAL    BONES  451 

The  fallacy  arising;  from  the  simultaneous  reception  of  other  injuries  which 
subseciuently  "•ive  rise  to  symptoms  of  intracranial  disturbances  should  not  be 
lost  sifi'ht  of. 

The  bullet  may  penetrate  the  skull  and  \-et  not  pass  through  the  dura  mater. 
The  missile  may  be  found  resting  on  the  dura,  or  lodged  between  the  dura  and 
the  inner  table  of  the  skull  at  the  site  of  the  wound,  or  at  a  point  more  or  less 
remote  from  the  original  point  of  entry.  This  may  occur  in  the  case  of  a 
"spent  ball,"  or  one  that  has  lost  most  of  its  projectile  force  immediately  after 
entering  the  skull.  In  these  cases  the  bullet  may  not  be  accessible  to  the  probe, 
and  may  be  discovered  only  by  the  Rontgen  rays  or  after  trephining. 

The  dura  mater  may  be  injured  by  the  splintered  fragments  of  the  skull, 
the  latter  being  driven  into  the  substance  of  the  brain,  the  bullet  assuming 
an  extradural  location.  The  missile  may  pass  but  a  short  distance  into  the 
brain  substance,  where  it  may  be  identified  after  trephining  and  enlarging  the 
opening  in  the  dura. 

When  both  tables  are  broken  the  greatest  amount  of  damage  is  inflicted  on 
the  inner  table;  this  is  according  to  T  e  e  v  a  n  '  s  law,  that  the  fracture  com- 
mences in  the  line  of  extension  rather  than  in  the  line  of  compression,  the 
internal  table  receiving  the  force  of  the  bullet,  plus  the  force  conveyed  by  the 
outer  to  the  inner  table.  In  perforating  wounds  the  force  at  the  point  of  exit 
is  applied  from  within  and  the  outer  table  is  more  extensively  splintered. 
Hence,  the  wound  of  exit  is  larger  than  that  of  entrance, 

A  bullet  in  its  passage  through  the  skull  produces  radiating  tears  of  the  brain, 
substance,  these  being  more  marked  in  the  gray  than  in  the  white  substance 
(T  i  1 1  m  a  n  n  s).  In  addition  to  the  missile  and  bone  splinters,  portions  of 
hair,  etc.,  may  be  present  in  the  brain  substance. 

The  probable  direction  taken  by  the  ball,  as  based  on  the  position  in  which 
the  firearm  was  held  at  the  time  of  the  shooting,  should  be  considered,  as  well 
as  an  inspection  of  the  opposite  side  of  the  head  made  for  the  presence  of  bulging 
or  other  evidences  of  fracture.  The  ball  may  strike  the  opposite  side  of  the  wall 
at  right  angles  to  the  surface  or  within  15  degrees  of  it  and  lodge  at  the 
point  of  impact  (Ruth).  Fluhrer,  Delbet  and  D  a  g  i  o  n  claim  that 
a  ricochet  takes  place  in  some  cases,  the  deflected  bullet  taking  a  secondary 
course  in  the  cranial  cavity.  According  to  R  u  t  h  ,  when  deflection  does  occur, 
it  is  almost  invariably  at  right  angles  of  more  than  90  degrees  to  the  angle  of 
incidence. 

In  probing  for  a  bullet  lodged  in  the  cranial  cavity  the  instrument  used 
should  ha^'e  a  spheric  tip,  and  in  order  to  minimize  the  friction  arising  from  its 
contact  with  the  collapsed  bullet  track  and  to  insure  that  all  resistance  to  be 
appreciated  by  the  hand  manipulating  the  probe  is  communicated  from  its  tip, 
the  tip  should  be  mounted  on  a  slender  shaft.  For  the  larger  sized  missiles 
a  probe  tip  one-fourth  of  an  inch  in  diameter  will  suffice  for  bullets  from  .32 
caliber  up,  and  one  three-sixteenths  of  an  inch  in  diameter  will  follow  the  track 
of  a  bullet  from  one  of  the  smaller  firearms.  The  extreme  limit  of  force  em- 
ployed in  the  case  of  the  first  named,  in  order  to  guard  against  driving  the  tip 
of  the  probe  into  the  brain  substance  or  between  the  convolutions,  is  from  two 
and  one-half  to  three  ounces  (R  u  t  h) .  In  order  to  determine  the  exact  amount 
of  force  employed,  the  graduated  pressure  probe  may  be  employed  (Fig.  243). 
The  handle  of  the  instrument  is  hollow  and  slides  on  the  stem  against  the 


452  THE  SURGERY  OF  THE  HEAD 

pressure  of  a  spiral  spring.  An  indicator  on  the  stem  and  a  scale  marked  in 
fractions  of  an  ounce  on  the  handle  serve  to  record  the  force  existing.  As  long 
as  the  probe  is  following  the  bullet  track,  the  pressure  to  propel  it  is  conve3'ed 
through  the  medium  of  the  spring,  and  this  is  recorded.  As  soon  as  the  limits 
of  the  spring  have  been  reached,  as  shown  by  the  indicator,  the  danger-point 
has  been  reached  and  the  probe  must  be  partially  withdrawn  and  its  course 
changed.  The  stem  of  the  instrument  is  insulated  with  a  coating  of  rubber  and 
has  a  connection  by  means  of  which  it  can  be  attached  to  a  telephone  receiver 
and  used  in  connection  with  the  Girdner  apparatus  (Fig.  164).  As  soon  as 
the  tip  of  the  instrument  comes  in  contact  with  the  bullet,  a  distinct  click  is 
heard   in   the   receiver. 

In  the  treatment  of  gunshot  wounds  of  the  head  the  first  care  of  the 
surgeon  will  be  to  bring  about  reaction,  and  in  case  of  respiratory  failure,  to 
make  artificial  respiration.  In  the  meanwhile  the  head  is  to  be  shaved  and 
every  aseptic  preparation  made.  The  scalp  is  to  be  turned  back  to  expose  the 
opening,  the  latter  enlarged,  splintered  bone  removed,  hemorrhage  arrested,  and 
the  dui'a  examined.  If  the  bullet  lies  on  the  latter,  it  is  to  be  removed 
wdth  the  dressing  forceps.  If  there  is  an  opening  in  the  dura,  the  bullet  is  to  be 
sought  for  beneath  this.  The  direction  from  which  the  shot  was  fired  having 
been  ascertained,  the  surgeon  will  be  in  a  position  to  calculate  the  probable 
direction  which  the  bullet  track  takes  in  the  brain.     If  the  bullet  is  located  near 


Fig.  243. — Graduated  Pressure  Bullet  Probe  for  Braix. 

the  wound  of  entrance,  it  is  to  be  removed  with  forceps.  If  located  nearer  the 
opposite  side,  a  trephine  counter-opening  is  to  be  made,  and,  with  the  probe 
held  in  position  by  an  assistant,  the  surgeon  may  explore  through  the  counter- 
opening,  passing  through  the  brain  substance  a  fine  steel  needle  with  the  sharp 
point  ground  off.  When  the  proper  direction  is  ascertained  and  the  exact 
location  of  the  bullet  identified,  it  may  be  removed  through  an  incision.  It 
should  always  be  borne  in  mind  that  the  surgeon  may  do  more  harm  by  ill 
directed  efforts  to  locate  and  remove  the  bullet  than  will  probably  result  from 
the  presence  of  the  latter.  Many  surgeons  are  contented  with  clearing  away 
the  bone  splinters  and  foreign  debris  at  the  wound  of  entrance  and  instituting 
tube  drainage  along  the  wound  track.  If  the  graduated  pressure  probe  with 
telephonic  attachment  fails  to  locate  the  missile,  the  operative  effort  should 
terminate  with  the  introduction  of  a  soft-rubber  drainage-tube  and  the  dressing 
of  the  wound ;  further  interference  should  be  postponed  until  localizing  symp- 
toms arise.  Bullets  frequently  become  encysted  and  give  rise  to  no  further 
trouble. 

NONTRAUMATIC  INFLAMMATION  OF  THE  CRANIAL  BONES 

Acute  infectious  osteomyelitis  and  tuberculous  inflammation  of  the 

bones  of  the  skull  may  iDoth  occur.  The  last  named,  though  of  infrequent 
occurrence,   is    not    bv  anv  means  so  rare  as  the  former.      In  tuberculous 


THE    CRANIAL    BOXES  453 

inflammation  of  the  cranial  bones  the  apphcation  of  the  trephine  in  such  a  man- 
ner as  to  remove  one  or  more  buttons  of  bone,  and  in  an  area  sufficient  to  include 
healthy  bone  as  well,  is  preferable  to  curetment,  in  order  to  secure  a  permanent 
result . 

S}philitic  caries  and  syphilitic  necrosis  of  the  skull  are  rather  more 
frequent  than  tuberculous  disease  of  the  cranial  bones.  The}'  occur  in  con- 
junction with  the  breaking  down  of  a  syphiloma  or  syphilitic  gumma.  The 
external  coverings  of  the  skull  may  ulcerate  first,  showing  a  necrotic  external 
table,  or  the  gumma  may  break  down  in  the  substance  of  the  bone  and  reach 
the  inner  table.  The  latter  condition  is  one  of  caries,  and  the  former  a  necrosis, 
both  of  which  may  occur  at  the  same  site.  Under  an  antisyphilitic  regimen 
the  smooth,  white,  external  table  of  the  skull,  which  appears  at  the  bottom  of 
the  syphilitic  ulcer,  is  gradually  replaced  by  little  islands  of  granulations  which 
spring  up  from  the  underlying  diploe  and  find  their  way  to  the  surface  of  the 
outer  table.  Occasionally  the  bared  portion  of  the  outer  table  is  lifted  up 
en  masse  by  the  underlying  granulations.  In  cranial  bones  bared  by  accident 
or  in  the  course  of  plastic  operative  procedures  the  same  process  of  repair 
occurs.  This  process,  formerly  known  as  insensible  exfoliation,  is  now 
known  to  be  result  of  the  tendency  of  the  granulations  to  dissolve  the  bone. 
Exfoliation  of  the  entire  tliickness  of  the  skull  may  also  occur  as  a  result  of 
syphilitic  necrosis,  in  which  case  pulsation  of  the  brain  may  be  recognized  after 
separation  or  removal  of  the  seciuestrum. 

Syphilitic  osteoma  results  from  a  sclerosed  condition  of  the  bones  of  the 
skull  in  which  the  syphilitic  deposit,  instead  of  proceeding  to  suppuration  and 
softening,  pursues  the  opposite  course. 

Suppurative  inflammation  of  the  medullary  substance  of  the  bones 
of  the  skull  occurs  almost  exclusively  in  connection  with  diseased  conditions 
of  the  mastoid  and  will  be  described  in  connection  with  inflammations  of  the 
ear  (see  page  583). 

The  ridgelike  prominences  wliich  are  sometimes  obserA-ed  along  the  lines  of 
the  sutures  and  are  easily  felt  by  the  fingers  are  due  to  rachitic  disease  of  the 
cranial  bones.  Likewise  the  persistence  of  open  fontanels  is  of  rachitic  origin, 
showing  an  irregularity  in  the  development  of  the  cranial  bones  which  pro- 
liferate from  the  suture  lines. 

Craniotabes  is  a  condition  observed  in  rachitic  children  in  which  limited 
areas  in  the  cranial  bones  undergo  softening  and  absorption.  Such  spots  yield 
under  the  pressure  of  the  finger  and  feel  like  wet  parchment.  They  occur  most 
frequently  over  areas  subjected  to  pressure,  like  the  parietal  and  occipital 
regions,  but  they  occasionally  appear  in  the  frontal  bone.  Rachitic  softening  of 
the  periosteum  also  occurs,  which  on  slight  injury  leads  to  extravasations  of 
blood  between  the  bone  and  the  periosteum  resembling  a  cephalhematoma 
of  the  newborn. 


TUMORS  OF  THE  CRANIAL  BONES 

Tumors  of  true  congenital  origin  must  be  very  rare,  as  none  are  on  record. 
Cephalhematoma,  however,  resulting  from  prolonged  pressure  on  the  head 
during  labor,  is  not  uncommon.  This  differs  from  the  so-cafled  caput  suc- 
cedaneum,  which,  while  of  similar  origin,  consists  of  a  general  edematous 
swelling  from  venous  stasis.     Cephalhematoma,  on  the  other  hand,  consists  of 


454 


THE    SURGERY    OF   THE    HEAD 


an  extravasation  of  blood  between  the  pericranium  and  the  bone.  Extra- 
vasation between  the  cranial  l^ones  and  the  dura  mater  has  been  found  in  the 
cadaver  of  the  newborn,  simultaneously  with  cephalhematoma.  If  the  effused 
blood  of  a  cephalhematoma  is  not  resorbed  in  the  course  of  a  few  weeks,  the 
elevated  periosteum  proceeds  to  the  formation  of  new  plates  of  bone  and  a 
parchment-like  crepitation  is  felt  beneath  the  palpating  finger.  These  bony 
plates  may  persist  and  finally  inclose  the  fluid  in  a  true  cyst  with  bony  walls. 
The  treatment  of  cephalhematoma  in  cases  in  which  no  perceptible  diminu- 
tion occurs  under  the  use  of  evaporating  lotions  continued  for  a  fortnight, 
consists  in  evacuating  the  contents  by  means  of  a  puncture  with  a  thin-bladed 
scalpel,  under  strict  antiseptic  precautions.  The  fluid  will  be  found  to  be 
chocolate-colored  and  devoid  of  fibrinous  clots.  Aspiration  of  the  fluid  is  also 
recommended.  Finally,  free  incision  may  become  necessary  in  order  to  effect 
a  cure.     Firm  compression  by  means  of  semielastic  bandages  should  follow 

either  puncture  or  aspiration.  A  conve- 
nient pressure  bandage  may  be  made 
from  ordinary  domestic  flannel,  the  strips 
being  cut  on  the  bias. 

Cranial  pneumatocele  is  a  name 
given  to  a  diffusion  of  air  between  the 
pericranium  and  the  bone.  The  air  finds 
its  way  into  this  abnormal  position  usu- 
ally through  some  defect  in  the  cancelli 
of  the  mastoid  portion  of  the  temporal 
bone.  Owing  to  the  fact  that  the  air  is 
filtered  through  cavities  lined  with  mu- 
cous membrane,  bacterial  infection  and 
inflammation  do  not  necessarily  follow. 
Acts  of  sneezing  may  be  the  exciting 
cause  of  the  condition.  By  firm  ban- 
daging the  air  can  sometimes  be  forced 
from  its  position,  escaping  through  the 
Eustachian  tube.  ITsually,  however, 
recurrence  takes  place.  Where,  as  some- 
times occurs,  the  entire  scalp  becomes 
"ballooned,"  evacuation  by  means  of  the 
trocar  may  be  necessary.  The  repeated  injection  of  tincture  of  iodin  has 
proved  successful  and  should  be  tried. 

Chondroma  of  the  cranial  bones  is  a  very  rare  affection.  Osteoma  of  the 
frontal  sinuses  is  described  elsewhere  (see  page  518).  Syphilitic  osteoma  has 
been  already  discussed  (see  page  453). 

Sarcoma  of  the  cranial  bones  originates  from  the  diploe.  It  usually  pro- 
ceeds toward  the  surface.  Those  sarcomatous  growths  which  involve  the 
dura  generally  have  their  origin  there.  The  prognosis  is  very  grave  and 
extirpation  is  usually  followed  by  recurrence.  The  orbit  is  frequently  the  seat 
of  sarcoma  (Fig.  244).  The  nasopharynx  is  also  a  favorite  location,  whence  the 
growth  may  extend  to  the  nasal  fossa  and  into  the  pharjoix,  or  perforate  the 
base  of  the  skull.  Sarcomas  arise  in  the  mucoperiosteal  structures  in  this 
locality.  Their  growth  is  accompanied  by  intense  headache  and  sometimes 
by  profuse  epistaxis. 


Fig.  244. — Sarcoma  of  the  Orbit. 


THE    BRAIN  455 


THE  BRAIN 

Contusions  of  the  Brain.— The.se  are  the  result  of  external  violence 
transmitted  from  tlie  skull  to  the  brain,  the  skull  itself  being  simultane- 
ously injured.  Direct  injury  without  involvement  of  the  skull  takes  place 
exceptionally  at  the  apex  of  the  orbital  cavity;  it  is  possible,  however,  for  only 
very  small  objects  to  enter  at  this  point  without  injurv'  to  the  bone. 

Sudden  changes  in  the  shape  of  the  skull,  the  latter  returning  at  once  to  its 
original  shape,  fractures,  and  other  injuries  of  the  bony  capsule,  may  produce 
solutions  of  continuity  of  the  brain  ti.ssue.  Contusions  are  more  frecjuenth^ 
observed  than  incised  or  lacerated  wounds,  owing  to  the  nonresisting  character 
of  the  brain  substance,  which  transmits  the  vulnerating  force  in  all  directioiLS. 

The  extent  of  the  damage  inflicted  will  vary  from  merely  punctate  hem- 
orrhages in  one  or  more  areas  to  the  crushing  of  an  entire  lobe  with  pulpifica- 
tion  of  the  brain  substance  in  which  fragments  of  bone  may  be  embedded,  and 
extensive  hemorrhage.  Or,  extensive  ruptures  located  in  different  areas  of  the 
brain  (multiple  lacerations  of  the  brain)  may  be  present.  Contusions  occur 
with  the  greatest  frequency  at  the  base;  in  spite  of  this  the  pons  varolii,  crura 
cerebri,  and  medulla  oblongata  often  escape  injury. 

Contusions  and  lacerations  of  the  brain  follow  a  course  corresponding  to 
the  extent  of  the  damage  inflicted.  The  symptoms  ma}^  be  transient,  recover}^ 
taking  place  in  a  few  days,  or  permanent  lesions  may  result  in  more  or  less 
permanent  impairment  of  function,  ^lany  weeks  or  even  months  may  elapse 
before  the  paratyses  and  psychic  disturbances  disappear.  In  other  cases 
abscesses  of  the  brain  may  follow.  In  cases  in  which  recovery  has  apparently 
taken  place  impairment  of  memor}'  may  exist,  and  psychic  disturbances, 
epilepsy,  etc.,  develop.  Again,  in  the  unfavorable  cases  the  paralyses  may  be 
permanent,  encephalitis  and  cerebral  softening  from  fatty  degeneration  of  the 
vessels  finally  destroying  the  patient. 

Slight  contusions  of  the  surface  may  result  in  but  little  apparent  disturbance 
of  the  functions  of  the  brain.  But  grave  symptoms  may  arise  from  severe 
contusions  and  lacerations.  The  latter,  occurring  at  the  base  in  the  posterior 
fossa,  are  almost  without  exception  immediately  fatal  on  account  of  the  im- 
portant ner\'Ous  centers  essential  to  life  that  are  involved  in  the  injur\^  SUght 
contusions  and  lacerations  occurring  anteriorly  may  interfere  simply  with  the 
functions  of  the  optic  and  olfactory-  nerv'es.  Disturbances  of  the  motor  oculi 
and  abducens  may  also  follow.  One  of  the  symptoms  peculiar  to  laceration 
of  the  brain  is  the  tendency  of  the  patient  to  lie  on  the  affected  side,  with  the 
knees  drawn  up  and  the  head  and  shoulders  depressed.  This  peculiar  position, 
in  which  nearly  all  of  the  flexors  of  the  body  take  part,  has  never  been  satis- 
factorily explained. 

After  recover\'  from  the  immediate  effects  of  contusion  and  laceration  of  the 
brain,  certain  symptoms  of  a  more  or  less  chronic  character  occur.  These 
include  paralysis  of  both  motion  and  sensation  in  the  upper  and  lower  extremi- 
ties. Other  important  symptoms  are  the  following:  Amnesia,  or  loss  of 
memory-;  aphasia,  or  incoordination  in  speech;  and  agraphia,  or  inability 
to  express  language  in  writing  (see  Cerebral  Localization,  page  466). 

Repair  takes  place  through  the  medium  of  the  connective-tissue  elements 


456  THE  SURGERY  OF  THE  HEAD 

and  vessels  of  the  pia  mater.  Regeneration  of  nerve-cells,  and  probal^ly 
of  nerve-fibers,  does  not  take  place  (T  s  c  h  i  s  t  o  w  i  t  s  c  h) .  The  process  of 
repair  may  occupy  weeks,  or  even  several  months.  In  cases  which  survive 
the  immediate  effects  of  the  injury  degenerative  processes  ("yellow  soften- 
ing") may  occur,  ha^'ing  but  few  or  no  symptoms  at  first  and  proving  suddenly 
fatal  at  the  last  (traumatic  late  apoplexy). 

Wounds  of  the  Brain. — Wounds  of  the  brain  are  to  be  distinguished, 
for  purposes  of  study,  from  contusions  of  the  brain,  in  that,  in  the  former  the 
lesions  take  place  in  conjunction  with  closed  (simple)  fractures  and  similar 
injuries,  wdiile  in  the  latter  the  injury  of  its  encasement  is  an  open  one,  or  one 
which  effects  a  communication  between  the  exterior  surface  and  the  brain. 
They  may  be  classified  as  contused,  punctured,  and  lacerated.  Wounds  of  the 
brain  may  occur  from  force  bluntly  applied,  from  sharp  objects,  or  from  both 
coincidentally  applied,  as,  for  instance,  when  a  blunt  object  produces  a  fracture 
of  the  skull,  a  splintered  fragment  causing  a  wound  of  the  brain.  Or,  a  sharp 
object  may  produce  a  contused  wound  of  the  brain,  the  outer  bony  structure 
neutralizing  the  force  at  the  diploe  and  the  splintering  of  the  latter  causing 
the  brain  injury. 

If  the  patient  survives  the  immediate  effects  of  the  injury  (shock  and 
hemorrhage)  the  future  course  of  the  case  will  depend  more  on  the  occurrence 
of  infection  than  on  all  other  circumstances  combined.  With  the  invasion  of 
the  traumatic  area  by  pus  microorganisms  suppurative  inflammation  develops 
and  encephalomeningitis  results.  This  is  usually  progressive  in  character. 
Exceptionally,  in  cases  in  which  opportunity  for  drainage  is  afforded  through 
the  existing  wound,  the  infectious  inflammatory  process  may  remain  localized 
and  healing  take  place.  Or,  with  the  arrest  of  free  escape  of  pus  from  the 
damaged  area  retention  occurs  and  an  abscess  results  (acute  traumatic  corti- 
cal abscess,  K  r  o  n  1  e  i  n). 

Intracranial  Hemorrhage. — The  predominating  symptoms  in  cases  of 
intracranial  injuries  are  those  arising  from  the  escape  of  blood  from  the 
vessels. 

Extradural  Hemorrhage. — This  may  take  place  with  or  without  fracture 
of  the  skull.  It  usually  occurs  from  rupture  of  one  of  the  branches  of  the  middle 
meningeal  artery,  the  blood  escaping  between  the  dura  and  the  skull.  Local 
compression  of  that  part  of  the  brain  lying  near  the  artery  will  be  the  first 
symptom,  and  diminution  or  loss  of  power  on  the  opposite  side  of  the  body  will 
follow.  The  most  important  feature  is  the  occurrence  of  a  well-marked  interval 
of  intelligence,  after  the  first  concussion,  between  the  reception  of  the  injur}^ 
and  the  supervention  of  symptoms  pointing  to  pressure  on  the  brain  svibstance, 
such  as  interference  with  motion  or  speech  if  the  effusion  of  blood  is  opposite  a 
portion  of  brain  presiding  over  these ;  or  hemiplegia,  stupor,  coma,  and  irregu- 
lar and  automatic  movements.  In  addition  to  the  above,  there  will  be  con- 
traction of  the  pupils,  followed  in  the  later  stages  by-  dilatation.  When  the 
compression  is  local,  the  pupil  may  be  dilated  and  immovable.  In  a  right- 
handed  person  aphasic  symptoms  occur  in  injury  of  the  left  side.  The  pulse 
is  slow  and  full  at  first,  but  becomes  more  rapid  as  compression  increases.  The 
breathing,  at  first  quiet,  becomes  stertorous,  and  convulsions  may  occur.  The 
hemorrhage  may  cease  spontaneously,  the  dura,  as  it  is  crowded  away  from 
the  skull  by  the  effused  blood,  making  pressure  on  the  point  of  rupture.     Mental 


THIO    BRAIN  457 

disturbances  will  persist,  however,  until  the  clot  is  resorl)cd,  and  traumatic 
(Jacksonian)  ej)ilepsy  may  result  from  the  irritation  arising  from  the  presence 
of  the  scar. 

Subdural  and  Subarachnoid  Hemorrhage. — Bleeding  in  these  situations 
is  often  combined,  and  when  the  hemorrhages  occur  separately  it  is  impossible 
to  differentiate  them  clinically.  In  most  instances  the  arachnoid  is  torn  and 
the  effusion  of  blood  takes  place  in  both  the  subdural  and  the  subarachnoid 
space.  Exceptionally,  a  true  subdural  hemorrhage  is  caused  by  injury  of  one 
of  the  sinuses  of  the  dura  mater,  or  by  a  coincident  rupture  of  the  middle 
meningeal  artery  and  dura  just  after  the  vessel  enters  the  skull  at  the  foramen 
spinosum.  A  true  subarachnoid  hemorrhage  may  follow  rupture  of  the  vessels 
of  the  pia  mater  without  a  tear  in  the  arachnoid. 

If  the  escape  of  blood  from  the  injured  vessel  is  rapid,  and  this  is  usually  the 
case,  symptoms  of  pressure  appear  quickl3^  The  lucid  interval  so  character- 
istic of  extradural  or  subcranial  hemorrhage  is  absent,  the  symptoms  of  con- 
cussion merging  into  those  of  compression.  In  the  exceptional  instances  in 
which  the  hemorrhage  takes  place  slowly,  the  cerebrospinal  fluid  is  gradually 
displaced  by  the  effused  blood,  and  symptoms  of  disturbance  of  brain  functions 
are  delayed  in  their  appearance.  In  subdural  hemorrhage  the  blood  tends  to 
gravitate  in  the  direction  of  the  basal  ganglia,  and  pressure  in  this  locality  gives 
rise  to  general  compression,  rather  than  to  special  symptoms,  the  respiratory 
center  becoming  involved  early. 

Intracerebral  Hemorrhage. — Nevertheless,  hemorrhage  from  the  vessels 
of  the  pia  takes  place  in  cases  of  contusion  and  w^ounds  of  the  brain.  It 
is  impossible  to  differentiate  clinically  this  variety  and  the  jd receding  except 
by  operation. 

Intraventricular  Hemorrhage. — Hemorrhage  into  the  lateral  ventricles 
can  take  place  only  as  the  result  of  very  extensive  injuries;  hence  it  is  of 
rare  occurrence.     Coma  sets  in  early  and  a  rapidly  fatal  termination  follows. 

(For  foreign  bodies  in  the  brain,  see  page  449.) 

The  Diagnosis  of  Brain  Injuries. — This  is  based  almost  exclusively 
on  the  localized  cerebral  symptoms  (Cerebral  Localization,  see  page  466). 
Special  difficulties  in  the  interpretation  of  these  are  present,  however, 
due  to  the  following:  (1)  the  manifestaton  of  concussion  and  compression 
masking  the  other  symptoms;  (2)  the  presence  of  multiple  and  differently 
located  lesions;  (3)  complex  symptoms  resulting  from  extensive  injuries  com- 
bined with  intrameningeal  hemorrhages;  (4)  the  presence  of  localized  injuries 
which  give  rise  to  no  topical  symptoms;  (5)  the  rapid  supervention  of  in- 
fection with  its  accompanying  s3miptoms  (see  Traumatic  Meningitis;  also 
Fractures  of  the  Skull). 

Traumatic  Meningitis. — This  is  alw^ays  the  result  of  infection,  most 
frecjuently  from  the  presence  of  Streptococcus  pyogenes  and  Staphylococcus 
pyogenes  aureus  (Mace  wen).  Infection  takes  place  almost  exclusively 
from  the  external  surface  of  the  body.  It  may  follow  directly  after  the 
injury  (early  meningitis)  or  develop  later  (late  meningitis).  The  first  occurs 
in  connection  with  the  reception  of  the  injury  or  in  the  course  of  the  healing 
of  the  wound.  The  late  form  may  appear  weeks  or  even  months  afterward; 
its  occurrence  is  favored  by  the  presence  of  splinters  of  bone,  foreign  bodies, 
and  other  sources  of  irritation.     The  pia  mater  and  arachnoid  are  more  com- 


458  THE  SURGERY  OF  THE  HEAD 

monly  involved  (leptomeningitis) ;  in  these  the  spread  of  the  infection  is  rapid. 
Traumatic  inflammation  of  the  dura  is  comparatively  rare  and  is  usually 
limited  to  the  place  of  injury  (see  page  443). 

Symptoms. — In  cases  of  early  meningitis  the  symptoms  are  usually  masked 
by  those  of  the  injurv,  and  in  late  cases  it  is  difficult  to  distinguish  them  from 
those  due  to  complicating  inflammatory  conditions,  such  as  suppurative  en- 
cephahtis,  abscess  of  the  brain,  etc.  In  cases  in  which  it  is  possible  to  separate 
the  symptoms,  these  will  include  chills,  fever,  headache,  nausea  and  vomiting, 
contracted  pupils,  restlessness  followed  by  delirium,  and  stupor  succeeded 
by  coma. 

Encephalitis  is  always  an  accompaniment  of  suppurative  meningitis. 
Under  these  circumstances  the  inflammation  follows  the  pia  and  affects  only 
the  superficial  portion  of  the  convolutions.  The  extensive  character  of  the 
inflammation  here  contributes  largely  to  the  fatal  result.  In  addition  to  cor- 
tical encephalitis  there  occurs  a  suppurative  inflammation  of  the  deeper  por- 
tions of  the  brain,  circumscribed  in  character,  constituting  abscess  of  the 
brain  (see  page  460). 

Diagnosis  of  Meningitis  and  Encephalitis. — The  occurrence  of  intra- 
cranial inflammation,  particularly  of  a  suppurative  character,  is  accompanied 
by  a  sudden  rise  of  temperature,  and  the  onset  of  severe  cephalalgia  at  or  near 
the  seat  of  injury.  A  chill  may  or  may  not  precede  the  temperature  eleva- 
tion. In  examination  of  the  wound  care  should  be  taken  to  exclude  erysipelas 
of  the  scalp  and  phlegmonous  inflammation  between  the  aponeurosis  of  the 
scalp  and  the  pericranium,  by  ascertaining  the  presence  or  absence  of  the 
characteristic  edematous  swelling  of  the  one,  or  the  combined  tenderness  and 
swelling  of  the  other,  if,  indeed,  these  have  not  preceded  the  intracranial 
inflammatory  involvement.  The  symptoms  of  the  one  may  overlap  those  of 
the  other. 

The  next  characteristic  symptom  is  gradual  loss  of  consciousness.  This 
course  marks  a  rapid  involvement  of  the  cerebral  surface  and  the  cortex  of 
the  hemispheres.  Cases  less  rapid  in  their  development  show  paralysis  of  the 
side  opposite  the  injury  and  convulsive  movements.  When  the  dura  is  exposed 
through  an  opening  in  the  skull,  it  has  been  suggested  that  increase  of  the 
pulsation  of  the  brain  is  a  sign  of  commencing  intracranial  inflammation. 
The  accumulation  of  serum  or  pus,  however,  increasing  the  tension  and  forc- 
ing the  dura  against  the  edges  of  the  opening,  will  lessen  the  visible  pulsations. 
This  latter  symptom  is  not  trustworthy,  particularly  in  focal  suppurative 
encephalitis  (brain  abscess),  for  the  reason  that  the  latter  has  been  shown  to  be 
present  in  conjunction  with  pulsation ;  on  the  other  hand,  a  number  of  conditions 
may  exist,  exclusive  of  brain  abscess,  which  lead  to  absence  of  pulsations. 
The  occurrence  of  convulsive  movements  of  the  ocular  muscles  indicates  the 
existence  of  a  basilar  meningitis. 

The  fever  of  meningitis  and  encephalitis  is  usually  of  a  continuous  charac- 
ter; variations,  if  any  occur,  are  not  extreme.  If  repeated  chills  occur,  or 
well-marked  exacerbations  of  fever  are  observed,  pyemia  is  indicated.  Death 
may  take  place  in  twenty-four  hours  from  the  commencement  of  the  attack 
or  be  postponed  for  several  days. 

Meningitis  of  traumatic  origin  and  cortical  encephalitis  cannot  clinically 
be  separated  from  each  other;  hence,  the  symptoms  in  the  above  description 
have  been  grouped  together. 


THE    BRAIN  459 

Abscess  of  the  brain  is  marked  by  a  slow  development,  the  symptoms 
pointing  to  disturbances  of  function  of  separate  portions  of  the  brain  and 
localized  headache.  In  the  beginning  the  fever  is  not  very  decided,  chills 
are  absent,  and  morning  remissions  are  the  rule.  Twitchings  or  convulsive 
movements  in  either  the  upper  or  the  lower  extremity  of  the  opposite  side 
ma}''  occur;  peripheral  paresis  or  paralysis  of  an  entire  extremity  or  of  sepa- 
rate groups  of  muscles  of  the  same  sjde  is  observed  (see  Cerebral  Localiza- 
tion, page  466).  The  symptoms  are  progressive  in  character  until  the  sup- 
purative focus  enlarges  sufficiently  to  reach  the  surface,  when  it  either  passes 
beyond  the  established  boundary  wall  and  infiltrates  the  surrounding  brain 
tissue,  or  a  violent  septic  meningitis  sets  in.  In  either  case,  death  soon  fol- 
lows (see  Abscess  of  the  Brain,  page  460).  In  differentiating  meningitis 
and  cortical  encephalitis  on  the  one  hand,  and  abscess  of  the  brain  on 
the  other,  the  time  of  the  occurrence  of  the  symptoms  should  be  considered 
in  their  relation  to  the  injury.  An  inflammation  which  occurs  during  the 
first  week  usually  indicates  the  former;  a  later  and  gradual  development, 
the  syhiptoms  being  of  the  character  above  described,  is  indicative  of  the  pres- 
ence of  cerebral  abscess.  Should  the  case  be  seen  sufficiently  early  an  ex- 
ploratory operation  is  indicated  in  view  of  the  hopelessness  of  this  class  of 
cases  when  purely  expectant  treatment  is  followed. 

The  prognosis  of  traumatic  meningitis  is  always  unfavorable  and  the 
treatment  in  the  main  unsatisfactory,  owing  to  the  opportunities  offered  for 
the  spread  of  the  infection  on  account  of  the  anatomic  structure  of  the  pia 
mater,  its  extensive  ramifications  and  the  rigid  bony  encasement  of  the  inflamed 
parts  and  consequent  early  pressure  on  vital  organs.  The  efforts  of  the  surgeon 
will  be  directed  mainly  to  its  prevention  by  the  exercise  of  a  most  thorough  and 
rigid  aseptic  regime  in  connection  wdth  all  cases  of  compound  fracture  of  the 
skull  or  wound  of  its  coverings.  With  the  first  sign  of  infection  the  wound 
should  be  opened  up  freely  and  the  surrounding  tissues  drained.  If  meningitis 
develops,  prompt  measures  must  be  taken  to  limit  the  infectious  process  by 
giving  exit  to  pent  up  secretions,  removing  blood-clots,  and  instituting  drainage. 
To  accomplish  this  the  opening  in  the  skull  must  be  enlarged  if  necessary,  and 
the  dura  incised  to  expose  the  pia  mater  as  much  as  possible. 

Hernia  Cerebri  (Acquired  Encephalocele).— By  this  is  meant  the  escape 
or  protrusion  of  brain  substance  from  the  cavity  of  the  skull.  It  occurs  most 
frequently  in  connection  with  gunshot  wounds  and  compound  fractures  with  loss 
of  bony  tissue.  It  may  follow  extensive  operative  attacks  on  the  skull  (craniec- 
tomy, etc.).  The  immediate  and  instantaneous  occurrence  of  gaping  of  a 
simple  fissure  may  permit  brain  substance  to  escape  when  this  takes  place  in 
connection  with  a  tear  in  the  dura  mater.  Syphilitic  caries  and  necrosis  rarely 
give  rise  to  it. 

Hernia  cerebri  may  be  primary  or  secondary.  In  the  primary  cases  the 
brain  substance  may  pour  out  at  once.  It  is  usually  accompanied  bj"  a  flow 
of  cerebrospinal  fluid,  which  may  continue  for  several  hours.  In  cases  of 
secondary  hernia  cerebri  the  protrusion  may  occur  in  the  first  week  following 
the  injury  or  it  may  be  delayed  for  several  weeks  (cerebral  prolapse).  Here 
the  portion  of  brain  not  separated  at  the  time  of  injury  is  gradually  protruded 
from  the  opening  in  the  dura  and  skull.  The  cause  of  the  protrusion  is  an 
abnormally  high  intracranial  pressure  due  to  the  inflammatory  processes  and 


460  THE  SURGERY  OF  THE  HEAD 

their  products  (exudates,  pus,  etc.).  In  cerebral  prolapse  the  protruding  mass 
slowly  increases  in  size  until  it  attains  the  size  of  a  walnut  or  is  even  larger. 
Distinct  pulsation  is  usually  present.  The  mass  soon  loses  the  normal  ap- 
pearance of  the  lirain  surface,  if  this  has  not  been  destroyed  at  the  time  of 
the  injury,  and  becomes  dark  or  black  and  softened  and  necrotic. 

The  diagnosis  may  be  usually  made  on  the  gross  appearances.  In  case  of 
doubt  microscopic  examination  should  be  made.  Extensive  granulations  due 
to  ulceration  of  the  surface  of  the  brain  may  cause  a  fungous  and  bleeding  mass 
(hemorrhagic  granuloma)  to  protrude  from  the  wound  and  simulate  hernia 
cerebri  {vide  infra). 

The  prognosis  will  depend  on  the  amount  of  brain  substance  extruded,  the 
importance  of  function  of  the  part  lost,  and,  above  all,  the  occurrence  or  non- 
occurrence of  infection.  Death  usually  takes  place  from  septic  encephalo- 
meningitis,  a  cerebral  abscess  developing  behind  the  protrusion.  In  the 
absence  of  infection  the  mass  is  cast  off,  the  remaining  portion  shrinking 
until  it  disappears  in  the  cranial  cavity. 

Treatment. — Shaving  off  the  prolapsed  mass  with  or  without  subsequent 
cauterization  is  recommended.  Attempts  to  cover  in  the  prolapsed  mass  by  a 
plastic  procedure,  consisting  of  transplanting  a  flap  attached  by  a  pedicle,  have 
succeeded  (Adams,   K  o  c  h  e  r). 

Hemorrhagic  Granuloma. — This  is  also  due  to  infection  arising  usually 
from  the  presence  of  splinters,  foreign  bodies,  or  other  sources  of  irritation 
occurring  in  an  open  wound  of  the  skull.  The  granulations  spring  from  an 
ulcerated  area  on  the  surface  of  the  brain.  The  protruding  mass  may  be 
the  size  of  a  walnut  or  larger.  It  is  soft,  pulsating,  bends  readily,  and  may 
contain  small  suppurating  foci.  Microscopic  examination  may  be  necessary 
to  distinguish  it  from  hernia  cerebri  (vide  supra).  Its  removal,  together  with 
splinters  of  bone,  foreign  body,  or  necrotic  tissue  that  may  be  present,  is  usually 
followed  by  cure. 

Abscess  of  the  Brain. — Abscess  of  the  brain  arises  from  (1)  traumatism 
(traumatic  abscess  of  the  brain) ;  (2)  disease  of  the  ear  (otitic  brain  abscess) ; 
(3)  infections  from  the  nasal  cavity ;  (4)  infectious  processes  on  the  skull 
(osteitis,  caries,  etc.) ;  (5)  metastasis  from  a  distance  (metastatic  brain  abscess). 
Traumatic  abscess  may  be  divided  into  the  acute  and  chronic  forms. 
The  acute  form  is  due  to  an  open  injury  of  the  skull,  usually  a  depressed  frac- 
ture with  injury  of  the  brain.  The  pia  mater  is  also  more  or  less  infected,  as 
a  rule  (leptomeningitis,  see  page  458).  The  latter,  if  it  assumes  the  diffuse 
purulent  form,  will  usually  prove  rapidly  fatal.  In  more  favorable  cases  the 
infectious  process  is  limited  to  the  seat  of  injury.  The  wound  of  the  scalp 
presents  the  characteristic  appearances  of  infection,  and  the  usual  constitutional 
manifestations  of  sepsis  are  present. 

Treatment. — Removal  of  depressed  portions  or  splinters  of  bone,  foreign 
bodies,  such  as  hair,  pieces  of  the  vulnerating  object,  etc.,  and  thorough  dis- 
infection of  the  surroundings  (see  page  432),  should  not  be  overlooked  in  the 
prophylaxis.  Efficient  drainage  should  be  provided  for.  The  simple  lifting 
up  of  a  neglected  depressed  fragment  which  has  prevented  the  escape  of  pus 
has  saved  many  lives  after  infection  had  occurred.  Even  with  traumatic  men- 
ingitis present  (see  page  457)  the  case  is  not  necessarily  hopeless.  The 
removal  of  infected  diploe,  exposure  and  incision  of  the  pia  mater,  with  the 


THE    BRAIX  461 

evacuation  of  purulent  material  and  thorough  drainage,  may  save  the 
patient. 

Chronic  Traumatic  Abscess  of  the  Brain. — The  chronic  form  may  follow 
the  acute  as  a  result  of  the  extension  of  the  infection  in  this  direction.  An 
acute  abscess  lasting  for  from  three  to  five  weeks  may  be  said  to  have  become 
chronic.  The  pus  caA-ity  is  usually  seated  in  the  medullar}-  substance  and  tends 
to  point  either  toward  the  surface  through  the  cortex  or.  in  the  case  of  abscess 
of  the  frontal  and  parietal  lobe,  toward  the  lateral  ventricle.  In  the  case  of 
abscesses  wliich  tend  to  peri'orate  the  cortex,  the  presence  of  adhesions  at  the 
site  of  the  original  injur}-  and  infection  may  prevent  purulent  extravasation 
beneath  the  pia  mater.  The  lodgment  of  foreign  liodies  carr\-ing  infection 
into  the  brain  substance  is  the  usual  cause  of  their  occurrence.  Brain  abscess 
which  occurs  at  points  comparatively  remote  from  the  original  point  of 
infection,  with  intervening  normal  brain  tissue,  are  probably  due  to  thrombo- 
phlebitis of  a  sinus. 

A  chronic  abscess  is  usually  lined  with  a  yellowish- white  capsule,  made 
up  of  a  layer  of  connective  tissue  (the  pyogenic  membrane  of  the  older  writers), 
and  may  remain  encapsulated  for  a  considerable  time,  this  sometimes  extend- 
ing over  a  period  of  months,  or  even  years,  and  involving  a  whole  lobe  or  even 
an  entire  hemisphere  without  producing  definite  symptoms;  extension  of 
infection  usually  takes  place,  however,  each  step  in  its  progress  being  marked 
by  a  fresh  attack  of  encephalitis  and  the  formation  of  new  and  adjacent  foci. 
Exceptionally,  in  favorable  cases  these  become  included  in  the  original 
ca^-ity.  In  the  absence  of  a  well-defined  capsule  a  rapid  increase  in  the  size  of 
the  abscess  takes  place:  this,  occurring  in  the  direction  of  the  cortex  and 
before  adhesions  form  at  the  site  of  the  pia  mater,  leads  to  diffuse  and  rapidly 
fatal  meningitis.  From  three  to  six  weeks  are  recjuired  for  the  development 
of  the  capsule. 

Symptoms. — In  chronic  traumatic  abscess  of  the  brain  the  primary  cerebral 
symptoms  var}-  in  different  cases  from  those  apparently  due  to  concussion 
to  well-defined  focalized  manifestations  according  to  the  site  of  injury.  In 
a  typic  case  these  subside,  and  the  patient  apparently  recovers.  The 
latent  period  which  foUows  may  be  marked  by  exacerbations  of  fever,  some 
confusion  of  thought,  mental  irritability,  irrational  acts,  headache,  and  diz- 
ziness. After  the  latent  period  the  secondary  symptoms  appear.  These 
also  var\-  greatly.  There  is  usually  fever,  though  this  is  not  a  pathognomonic 
symptom,  since  it  may  occur  in  diffuse  meningitis.  The  occurrence  of  a  chill 
is  not  a  constant  symptom.  The  headache,  which  is  referred  to  the  injured 
region,  usually  becomes  intensified,  jDarticularly  m  certain  movements  of  the 
body.  Neuralgic  pains  in  the  distribution  of  the  fifth  ner^-e  are  present, 
as  a  rule,  and  constitute  a  ver\-  suggestive  symptom  in  this  connection.  In- 
crease of  the  symptoms  is  due  to  variations  in  cerebral  pressure,  and  increase 
of  fever  is  coincident  with  extension  of  infection  and  the  occurrence  of  fresh 
suppuration.  The  symptoms  subside  and  reappear  until  the  so-caUed 
terminal  stage  is  ushered  in.  With  the  advent  of  this  extension  cerebral 
edema  occurs,  and  death  takes  place  from  this  cause  or  from  rupture  into  a 
ventricle. 

Diagnosis. — This  must  rest  largely  on  the  histor\-  of  apparent  recover^' 
from  the  injur\-.  the  intervening  latent  or  semilatent  period,  the  super^'ention 


462  THE  SURGERY  OF  THE  HEAD 

of  the  secondary  symptoms,  and,  finally  and  chiefly,  the  localizing  mani- 
festations (see  page  466,  Cerebral  Localization).  The  appearance  of  pus 
flowing  from  a  fissure,  or  from  between  two  fragments,  in  cases  in  whicli  the 
wound  remains  unhealed,  together  with  a  septic  condition  of  the  latter,  will 
demand  investigation.  Pyemia  is  to  be  excluded  if  chills  are  absent  or  in- 
frequent and  atypic,  and  if  there  are  no  other  manifestations  of  this  condi- 
tion present,  as  joint  involvement,  etc. 

Treatment. — The  invariably  fatal  termination  to  which  chronic  trau- 
matic abscess  of  the  brain  leads,  unless  evacuated,  imperatively  demands 
operative  interference.  In  doubtful  cases  presenting  evidences  of  a  grave 
intracranial  condition,  it  is  better  to  make  an  exploratory  investigation  than 
to  defer  interference  until  there  is  but  slight  or  no  hope  of  the  patient's 
recovery.  Drainage  must  be  obtained  at  all  hazards.  This  may  follow  on 
the  removal  of  a  fragment  of  bone.  If  evidence  of  pus  is  not  obtained  by 
this  procedure,  or  its  escape  is  not  deemed  sufficiently  free,-  the  ojoening  in 
the  skull  is  to  be  enlarged.  The  dura  must  be  incised  if  this  is  tense,  or 
pressed  outward,  or  if  pulsation  is  absent.  The  dura  may  be  discolored  or 
gangrenous  in  appearance.  If  these  signs  are  not  found,  and  if  there  are  no 
evidences  of  an  abscess  on  opening  the  dura,  the  cerebral  tissue  itself  should 
be  thoroughly  explored. 

Otitic  Cerebral  Abscess. — Abscesses  of  otitic  origin  follow  chronic  otitic 
suppuration  in  the  vast  majority  of  cases.  The  infectious  process  usually 
has  its  origin  in  caries  of  the  attic,  the  suppuration  extending  thence  through 
the  roof  of  the  tympanic  cavity.  Or,  the  suppurative  process  may  spread 
to  the  mastoid  antrum.  In  the  latter  case  the  pus  accumulates  in  the  mas- 
toid cells,  with  possible  perforation  of  the  outer  bony  layer,  or  an  extradural 
abscess  may  form  from  infection  of  the  lateral  sinus.  The  suppuration  may 
extend  beneath  the  tentorium  and  form  a  cerebellar  abscess.  With  symptoms 
of  mastoiditis  present  in  a  case  of  abscess  of  the  brain  of  otitic  origin,  there- 
fore, either  an  extradural  abscess  from  infection  of  the  lateral  sinus  or  a  cere- 
bellar abscess  exists.  In  the  absence  of  mastoiditis  the  suppuration  focus 
is  most  likely  to  be  found  in  the  temporal  region.  Both  conditions  may 
coexist,  however. 

Diagnosis. — The  signs  of  intracranial  suppuration  (remittent  temperature 
variations  and  increased  intracranial  pressure)  are  present  in  otitic  abscess, 
whether  situated  in  the  cerebrum  or  the  cerebellum.  In  suppurative  mas- 
toiditis with  intracranial  complication  the  attacks  of  fever  are  intermittent 
and  of  short  duration  and  the  period  of  freedom  longer.  Intracranial  sup- 
puration gives  rise  to  headache  and  vomiting  from  increased  and  varying 
intracranial  pressure.  The  headache  is  subject  to  evening  exacerbations, 
with  rise  in  the  temperature.  It  may  be. increased  by  percussion  on  the 
affected  side.  An  attack  of  vomiting  may  be  produced  by  a  sudden  change 
in  the  position  of  the  patient.  Choked  disc,  also  due  to  the  latter,  is  present, 
and  is  a  valuable  diagnostic  sign.  Distinctly  focalizing  symptoms  are  absent 
in  the  great  majority  of  cases. 

Treatment. — The  abscess  cavity  must  be  evacuated  and  drained.  In  the 
case  of  abscess  in  the  temporal  lobe,  this  may  be  reached  through  the  antrum 
and  tympanic  cavity  (8  c  h  w  a  r  t  z  e  and  S  t  a  c  k  e).  Or,  the  suprameatal 
fossa  and  squamous  portion  of  the  temporal  bone  may  be  exposed  by  turning 


THE    BRAIX 


463 


up  a  flap  between  the  middle  and  the  posterior  vertical  line  of  K  r  6  n  1  e  i  n  (Fig. 
245).  These  lines  of  incision  are  joined  by  a  third  commencing  at  the  top  of  the 
tragus  and  crossing  above  the  i)inna.  A  rectangular  opening  is  made  in  the 
bone  corresponding  to  the  exposetl  area.  This  opening,  extended  anteriorly, 
will  expose  the  neighborhood  of  the  Gasserian  ganglion ;  if  extended  backward, 
the  groove  for  the  transverse  sinus  can  be  reached.  It  will  also  permit 
exploration  of  the  usual  site  of  otitic  cerebellar  abscesses. 

The  opening  in  the  abscess,  if  such  already  exists,  is  to  be  dilated  bluntly 
and  a  drainage-tube  introduced.  Drainage  should  be  maintained  long  enough 
to  insure  complete  emptying.  If  cerebral  prolapse  occurs,  lhis  is  due  either  to 
a  reaccumulation  of  pus, 

or  to  a  collection  of  cere-  ^ 

brospinal  fluid  in  an  ad- 
jacent ventricle.  In  case 
of  the  latter  lumbar 
puncture  is  recommended 
(K  r  o  n  1  e  i  n). 

Cerebral  Abscess  of 
Nasal  Origin, — TMs  is 
caused  Ijy  suppuration  in 
the  upper  nasal  spaces 
and  their  accessory  cavi- 
ties. The  infection  may 
reach  the  brain  by  per- 
forating the  walls  of 
either  the  frontal,  the 
sphenoidal,  or  the  max- 
illary' sinus,  or  from  the 
ethmoid  cells,  or  it  may 
follow  the  vessels  (throm- 
bophlebitis) .  The  collec- 
tion of  pus  may  be  extra- 
dural, or  a  true  abscess 
of  the  brain  may  be  pre- 
sent. Thrombosis  of  the 
cavernous  sinus  or  lepto- 
meningitis may  occur. 
Rarely,  the  temporal  lobe 
is  involved. 

Symptoms. — T  h  e  s  e 
.  are  wearmess,  restlessness,  headache,  mental  apathy,  and  vomiting.      Choked 
disc  is  present.     Focalizing  symptoms  are  absent  except  in  cases  of  large 
abscess  producing  pressure  on  the  motor  centers. 

Treatment.— The  frontal  sinus  should  be  opened,  its  pcsteriorwaU  removed, 
if  this  has  not  been  already  destroyed,  the  dura  opened  if  necessary-,  and  the 
frontal  lobe  explored.     Tube  drainage  should  be  employed. 

Cerebral  Abscess  Developing  from  Disease  of  the  Skull.— Cerebral 
abscess  mav  arise  from  osteomyelitis  or  caries  of  the  bones  of  the  skull,  of 
traumatic,  tuberculous,  or  syphilitic  origin. 


Fig.  245. — Rroxleix's  Craniocerebral  Topographic  Lines. 
1  1  Base  line,  passing  through  the  infraorbital  ridge  and  the 
•superior  border  of  the  audit  or  v  meatus;  2,  2,  superior  horizontal 
line,  passing  through  the  supraorbital  ndge  parallel  to  the  base 
hne;  3.  .3,  anterior  vertical  hne,  parsing  from  the  middle  of  the 
zygomatic  arch  perpendicular  to  the  base  hne;  4.  4,  middle  vertical 
line,  passing  from  the  head  of  the  inferior  maxilla  (immechately  m 
froiit  of  the  tragus)  perpendicular  to  the  base  hne:  5,  .5,  posterior 
vertical  hne,  passing  from  the  posterior  palpable  margin  of  the 
mastoid  process  perpendicular  to  the  base  hne;  3.  6,  line  of  fissure 
of  Rolando  (see  p.  467) ;  3,  7,  line  of  fissure  of  Syh-ius. 


464  THE    SURGIORY    OF    THE    HEAD 

Metastatic  Cerebral  Abscesses. — These  arise  most  frequently  from 
infected  emboli  originating  in  intrathoracic  suppurative  disease  (gangrene  of  the 
lung,  old  empyema,  etc.).  The  emljoli  follow  the  most  direct  route  from  the 
aorta,  namely,  through  the  left  carotid  and  one  or  more  of  its  terminal  branches, 
finally  lodging  in  the  fossa  of  Sylvius.  They  are  usually  multiple,  and  the 
prognosis  is,  therefore,  unfavorable.  They  may  be  simple,  however,  and  hence 
efforts  at  operative  relief  are  not  excluded. 

Infectious  Sinus  Thrombosis. — This  may  arise  from  any  infectious 
inflammation  of  the  soft  parts  of  the  head  and  face  (erysipelas,  anthrax,  etc.); 
from  severe  infections  of  the  adjacent  cavities  (oral,  buccal,  nasal,  or  pharyn- 
geal) ;  or  from  infectious  processes  in  the  bones  (caries  of  the  temporal  bone 
from  ear  disease,  periostitis  of  the  jaw  from  a  carious  tooth,  etc.).  Its  most 
common  origin  is  in  a  suppurative  mastoiditis  following  disease  of  the  ear. 
In  this  connection  it  occurs  with  greatest  frequency  on  the  right  side,  is  most 
commonly  observed  in  male  subjects,  and  is  practically  limited  to  the  middle 
period  of  life.  It  usually  develops  by  continuity  to  the  wall  of  the  sinus  and 
there  is  a  resulting  thrombophlebitis  of  the  latter.  It  may,  however,  extend 
from  a  thrombophlebitis  of  a  vein  in  the  primary  focus.  When  extending 
directly  to  the  sinus  from  disease  of  the  mastoid,  the  inflammatory  process  as 
it  reaches  the  sigmoid  fossa  invades  the  sigmoid  sinus,  whence  the  infection 
spreads,  extending  in  many  cases  to  the  lateral  sinus  and  sometimes  to  the 
internal  jugular  vein,  or  even  to  the  superior  vena  cava.  The  thrombus  breaks 
down  and  a  purulent  collection  takes  place  within  the  sinus.  More  or  less 
widely  scattered  embolic  infection  from  attached  fragments  of  the  thrombus 
is  the  rule  (see  Pyemia,  page  184) .  Metastatic  abscesses  may  occur  in  the 
brain. 

When  thrombosis  of  the  two  petrosal  sinuses  is  present,  this  usually  coexists 
with  the  sigmoid  affection.  The  disease  as  it  attacks  the  cavernous  sinus  is 
generally  bilateral. 

Symptoms. — The  symptomatology  of  infectious  sinus  phlebitis  is  that  of 
pyemic  infection,  plus  disturbances  of  brain  function  (see  page  466,  Cerebral 
Localization).  Headache  is  an  early  and  important  symptom.  Dizziness 
and  vomiting  are  present.  The  fever  is  usually  intermittent.  The  tempera- 
ture, however,  ma}-  sink  to  the  normal  or  may  even  fall  below  it.  Edema  in 
and  about  the  mastoid  region,  and  tenderness  over  the  jugular  vein,  together 
with  the  presence  of  a  hard  cord,  are  diagnostic  in  cases  originating  in  mastoid- 
itis. Pressure  on  the  nerves  which  accompany  the  sigmoid  sinus  through  the 
foramen  (pneumogastric,  spinal  accessory,  and  glossopharyngeal)  may  occur 
and  cause  symptoms  of  compression  and  paralysis. 

Repeated  chills  usher  in  the  pyemic  condition  in  the  course  of  two  or  three 
days.  The  latter  is  marked  by  the  occurrence  of  pulmonary  complications 
(abscess  and  gangrene  of  the  lungs).  Such  small  emboli  as  pass  the  larger 
pulmonary  capillaries  lodge  in  the  other  organs  (liver,  spleen,  kidneys,  joints, 
sheaths  of  tendons,  etc.)  and  cause  characteristic  symptoms,  the  most  strik- 
ing of  which  is  jaundice,  which  develops  coincidentally  with  enlargement  and 
tenderness  of  the  liver.     Septic  endocarditis  may  occur  as  a  complication. 

Thrombosis  of  the  petrosal  sinuses  causes  no  special  local  symptoms. 
Thrombosis  of  the  longitudinal  sinus  may  cause  edema  of  the  scalp  and 
dilatation  of  the  superficial  veins.     Thrombosis  of  the  cavernous  and  trans- 


THE    BRAIX  465 

verse  sinuses  may  cause  exophthalmia  from  retrobulbar  edema,  and  edema 
t)l'  the  upper  lid.  Xerve  pressure  will  cause  neuralgia  in  the  ophthalmic 
division  of  the  trigeminus;  isolated  paralyses  of  the  eye  muscles  give  rise  to 
abnormal  positions  of  the  globe  and  contracted  pupils  and  ptosis.  Total 
ophthalmoplegia  may  be  present.  Amaurosis  may  result  from  optic  nerve 
pressure. 

Diagnosis. — This  depends  on  the  local  and  general  symptoms  combined. 
The  disease  is  most  likely  to  be  mistaken  for  typhoid  fever,  malaria,  and 
miliary  tuberculosis.  Septic  endocarditis  occurring  independently,  and  the 
presence  of  a  cerebral  abscess,  may  complicate  the  diagnosis.  The  history 
of  a  recent  aural  suppuration,  and  the  presence  of  mastoiditis  followed  by 
edema,  infiltration,  or  subperitoneal  pus  formation  in  the  neighborhood  of 
the  mastoid,  and  later  by  tenderness  and  thickenuig  m  the  course  of  the 
jugular  vein  on  the  corresponding  side,  serve  to  distinguish  the  affection  as  it 
exists  m  the  sigmoid  smus.  Edema  of  the  eyelid  and  within  the  orbit  and 
symptoms  of  nerve  pressure  in  this  neighborhood  point  to  involvement  of 
either  the  cavernous  or  the  transverse  sinus,  or  of  both. 

The  prognosis  m  cases  of  even  moderate  severity  of  mfection  is  unfa^or- 
able,  in  the  absence  of  operative  treatment.  Early  diagnosis  and  prompt 
operative  mterference  govern  the  outlook  for  recovery  more  than  all  other 
considerations  combmed. 

Treatment. — Prophylaxis  demands  the  careful  treatment  of  cases  of 
aural  suppuration,  early  openmg  of  the  mastoid  m  doubtful  cases,  and 
the  antiseptic  treatment  of  aU  mfections  withm  the  area  from  which 
they  can  be  transmitted  to  the  cranial  ca^'ity.  Infection  of  the  sigmoid 
sinus  demands  the  following:  (1)  Opening  of  the  mastoid  and  thorough 
removal  of  the  primary  focus.  (2)  Exposure  of  the  smus  and  its  explora- 
tion by  pimcture.  If  JBuid  blood  fails  to  follow  the  punctiu'e.  the  sinus 
is  thrombosed.  (3)  Evacuation  of  the  sinus  through  a  half-inch  vertical 
incision  and  the  removal  of  the  clot  with  forceps  or  a  small  sharp  spoon  to 
an  extent  sufficient  to  insure  disintegration  of  the  remainder  and  efficient 
drainage.  If  the  upper  two-thu'ds  of  the  sinus  can  be  evacuated  and  effici- 
ently drained,  this  may  be  deemed  sufficient.  (4)  If  a  decomposed  throm- 
bus extends  below  the  openmg  in  the  sinus,  drainage  must  be  obtained  at  a 
lower  point  and  the  jugular  vein  ligated  in  a  healthy  portion  of  the  vessel 
low  do\Mi  m  the  neck  and  excised.  If  the  vein  is  palpably  affected,  pre- 
limmar\'  excision  is  indicated,  both  for  prophylactic  and  aseptic  reason. 
In  hgating  the  vein  the  procedure  is  similar  to  that  for  ligation  of  the  caro- 
tid artery  (see  page  632).  The  vein  should  be  ligated  m  two  places  and  excised 
for  its  entire  length  between  the  ligatures. 

Intracranial  Tumors.— Of  the  mtracranial  tumors  most  freciuently 
observed,  23  per  cent  are  tuberculous  gro^^■ths,  13  per  cent  gliomas,  13  per 
cent  sarcomas.  5  per  cent  hydatids.  4.6  per  cent  cysts.  4  per  cent  carcmomas, 
3.6  per  cent  gummas,  2.2  per  cent  gliosarcomas.  and  2  per  cent  myxosarcomas.* 
Of  these.  tubercrJous  growths  are  most  frequent  m  early  life,  while  the  mahg- 
nant  forms  are  more  common  from  the  twentieth  to  the  fortieth  year. 

As  a  rule,  to  which,  however,  there  are  exceptions,  tumors  of  a  mahgnant 

*These  figures  are  taken  from  AMiite  and  Bernliardt's  statistics  as  tabulated  by  Seguin 
and  Weir  ("'American  Text-Book  of  Surgerj""). 
31 


466  THE  SURGERY  OF  THE  HEAD 

character,  as  -well  as  tuberculous  lesions,  tend  to  infiltrate  the  surrounding 
tissues.  Benign  growths  are  either  inclosed  in  a  well-defined  capsule,  as, 
for  instance,  in  the  case  of  cysts,  or  have  distinct  boundaries  which  separate 
them  from  the  neighboring  structures. 

Only  those  tumors  of  the  brain  which  possess  a  surgical  interest  \\ill  be 
considered  in  this  connection.  The  inquiry  A^ill  be  limited,  therefore,  to  those 
situated  in  the  motor  area  and  the  adjacent  regions  (central  con\-olutions). 
T-ess  than  25  per  cent  of  brain  tumors  are  accessible  to  operati\-e  interference 
(0  p  p  e  n  h  e  i  m) . 

Symptoms  of  Tumors  of  the  Brain. — The  clinical  symptoms  of  those 
tumors  included  in  the  present  study  will  comprise  the  following:  (1)  gen- 
eral brain  symptoms  or  those  caused  by  compression  of  the  brain;  (2)  local 
symptoms.  Of  the  general  symptoms,  the  most  important,  on  account  of 
its  frequenc}',  is  headache.  It  occurs  early,  is  constant  and  severe,  and  is 
migrainelike  in  its  dull  and  bormg  character.  It  is  likely  to  be  accompanied 
by  nausea  and  voixdting.  When  the  tumor  is  superficially  situated,  the  head- 
ache may  correspond  to  the  site  of  the  growth;  generally,  however,  it  is  dif- 
fused. The  next  most  important  general  symptom  in  this  connection  is  vomit- 
ing. This  usuahy  occurs  without  effort  and  from  an  empty  stomach  (men- 
ingeal or  cerebral  vomiting).  Finally,  choked  disc,  or  stasis  of  the  visible 
veins  in  the  fundus  of  the  eye,  when  present,  is  of  the  greatest  importance, 
it  is  absent,  however,  in  about  40  per  cent  of  cases  of  tumor  in  and  about 
the  central  fissure.  It  may  be  due  to  obstruction  in  the  circulation  caused 
by  increased  tension  of  the  cerebrospinal  fluid,  or  it  may  arise  from  direct  pres- 
sure on  large  venous  tnmks.  When  unilateral  the  tumor,  as  a  rule,  is  situated 
m  the  opposite  hemisphere.  Usually,  however,  it  is  bilateral.  It  does  not 
interfere  with  vision  until  secondary-  changes  in  the  optic  nerve  take  place. 

Of  the  local  sj^mptoms,  localized  convulsions  are  of  the  first  importance, 
particularly  when  these  have  been  preceded  by  disturbances  of  sensibility  or 
of  muscular  sense.  The  convulsions  are  at  first  tonic,  then  clonic  in  character, 
and  usually  begin  in  some  definite  group  of  muscles.  As  a  nde,  they  follow 
a  fixed  sequence  in  the  manner  of  their  extension  (see  page  468,  monospasm). 
The  occurrence  of  unconsciousness  is  marked  in  proportion  to  the  severity, 
extent,  and  length  of  the  convulsive  seizures  and  the  frequency  of  their  re- 
currence. Finally,  the  paralyses  which  eventually  follow,  while  but  temporary 
at  first,  soon  become  permanent  (see  page  468,  monoplegia),  and  the  spasms  of 
the  affected  muscles  cease  except  for  the  occurrence  of  slight  twitchings  during 
the  seizure. 

CEREBRAL  LOCALIZATION 

In  this  connection  the  symptoms  arising  from  interference  with  the  functions 
of  the  cerebral  organs,  either  from  injury  or  from  tumor  formation,  will  be 
considered.  It  is  obvious  that  these  symptoms  can  be  of  service  only  when 
the  lesion  occurs  in  a  part  of  the  brain  the  physiology  of  which  is  known.  In 
the  surgical  sense  the  most  important  region  of  the  brain  is  that  known  as  the 
motor  area.  This  includes  the  central  portion  of  both  central  convolutions,  the 
paracentral  lobule,  the  operculum,  and  the  foot  of  the  third  frontal  convo- 
lution. The  fissure  of  Rolando,  from  its  proximity  to  this  area,  serves  as  a 
guide  to  the  surgeon  for  the  location  of  those  portions  of  the  area  whose  func- 


THE    BRAIN 


467 


Fig.  246. — Motor  and  Sensory  Centers  op  the  Brain. 


tions  have  been  demonstrated  to  exist.     These  are  as  follows:  (1)  the  motor 

center  for  the  leg;  (2)  the  motor  center  for  the  arm;  (3)  the  motor  center  for 

the  head  (Fig.  246).     In 

all   prol)al)ility  these  re- 
gions are  also  the  seat  of 

cutaneous  sensil)ility  and 

of  muscular  sense. 

The  Fissure  of  Ro= 

lando.  —  According     to 

Thane,  this  fissure  com- 
mences  at  a    point  55.7 

per  cent  of  the  distance 

between  the  glabella  and 

the   inion,    measured  on 

the  median  line.     It  runs 

downward    and    forward 

at  an  angle  of  about  67 

degrees,  with  an  average 

length  of  3|  inches.     The 

following      is     a     ready 

method   of   locating   the 

fissure    (Fig.    247):     (1) 

Draw   a    line    from    the 

glabella  to  the  inion  with 

an     anilin     pencil,     and 

mark  a  point  half  an  inch 

behind  the  midway  point  of  this  line;   this  represents  the  commencement  of 

the  fissure;  (2)    select  a  piece   of   stiff   paper   or  light    cardboard  4  inches 

square,  fold  it  diagonally  on  the  line  AC,  bringing  the  edge  AD  to  corre- 
spond with  the  line  AC;  (3)  place  the 
card  with  the  point  A  at  the  com- 
mencement of  the  fissure,  and  the  edge 
AB  on  the  middle  line,  when  the  folded 
edge  AE  will  mark  the  site  of  the  fissure 
sufficiently  near  for  all  practical  jour- 
poses  (C  h  i  e  n  e). 

Lesions  of  the  Motor  Area.— It  is 
impossible  in  any  given  case  to  exclude 
participation  of  the  medullary  substance 
in  injuries  of  the  cortical  area.  Further, 
cortical  lesions  may  be  so  slight  or  involve 
so  unimportant  a  focus  as  to  give  rise  to 
no  focalizing  symptoms;  on  the  other 
hand,  these  may  be  so  extensive  as  to 
cause  total  destruction  of  both  central 
convolutions.  Finally,  as  more  fre- 
quently happens,  there  may  be  partial 

destruction  of  both  central  convolutions,  in  which  case  the  focalizing  symp- 
toms are  both  definitely  expressed  and  characteristic.     The  most  important 

of  these  are  monospasm  and  monoplegia. 


Fig.  247. — Chiene's  Device    for   Locating 
THE    Fissure     of    Rolando    (Reduced 

Size). 


468  THE    SURGERY    OF    THP:    HEAD 

Monospasm,  or  convulsive  movements  limited  to  a  single  group  of  muscles, 
is  a  symptom  of  value  in  the  diagnosis  of  lesions  of  the  motor  area.  'J'hese 
movements  are  caused  b}'  mechanic  irritation  arising  from  the  presence  of 
foreign  bodies,  tumors,  etc.  They  are  at  first  tonic  and  then  clonic.  The 
convulsion  always  begins  in  that  group  of  muscles  in  whose  center  the  irritation 
occurs.  In  the  case  of  a  tumor,  extension  of  the  convulsive  movements,  cor- 
responding to  the  area  involved,  takes  place  with  its  growth.  The  convulsion 
may  affect  first  the  face,  then  the  finger,  hand,  arm,  leg,  foot,  and  toes;  or 
in  the  reverse  order  (Jacksonian  epilepsy).  The  convulsions  are  succeeded 
by  permanent  monoplegia,  later  by  combined  monoplegia;  finally,  with  de- 
struction of  the  motor  centers,  complete  hemiplegia  develops  and  the  convul- 
sions cease.  Contractures  occur  (combined  paralysis  and  rigiditj^  in  the  groups 
of  muscles,  the  former  seat  of  the  convulsions,  together  with  pain,  paresthesia, 
and  dulled  sensation  from  involvement  of  the  sensory  area.  This  transition 
from  monospasm  into  localized  paralysis  constitutes  a  most  important 
diagnostic  sign.  The  monospasm  alone  may  be  due  to  pressure  on  the  motor 
area  by  a  lesion  situated  in  one  of  the  neighboring  lobes,  either  the  frontal, 
the  parietal,  or  the  temporal.  In  the  case  of  a  subcortical  tumor  the  effect 
is  the  same. 

Monoplegia,  or  paralysis  of  a  single  limb,  may  occur  as  a  pure  symptom,  or 
the  paralysis  may  affect  the  upper  and  lower  extremity  simultaneously.  The 
interposition  of  the  arm  center  prevents  simultaneous  occurrence  of  symptoms 
referable  to  the  leg  and  head  centers  without  involvement  of  the  former.  A 
pure  monoplegia  is  most  frequently  observed  in  connection  with  lesions  of  that 
portion  of  the  leg  center  represented  by  the  upper  third  of  the  anterior  central 
convolution  and  the  paracentral  lobule.  In  the  case  of  monoplegia  of  the  arm 
the  lesions  have  been  found  in  the  cortex  of  the  middle  third  of  the  central 
convolution  and  in  the  adjacent  sulci.  Lesions  of  the  leg  and  arm  centers  are 
the  favorite  starting-point  for  Jacksonian  epilepsy. 

Lesions  of  the  Parietal  Lobes. — These  do  not  give  rise  to  distinctly 
focalizing  symptoms  for  the  reason  that  the  functions  of  this  part  of 
the  brain  are  but  little  known.  "\^Tien  on  the  left  side  and  partly  on  the 
angular  gyms',  optic  and  sensory  aphasia,  with  disturbances  of  reading  (alexia, 
or  word  blindness),  probably  caused  by  the  intermption  of  connectmg  tracts 
between  the  visual  center  in  the  occipital  lobe  and  the  speech  center  in  the 
left  temporal  lobe,  have  been  observed.  Muscular  sense  may  also  be  inter- 
fered with.  Remote  effects  of  tumor  pressure  on  neighboring  centers  (motor 
area,  sensory  area  of  the  cortex,  posterior  section  of  the  internal  capsule, 
and  the  occipital  lobe)  ^^■ill  cause  corresponding  focahzing  symptoms. 

The  frontal  lobes  are  the  seat  of  the  mentality.  Lesions  of  these  are  fol- 
lowed by  weakness  of  memory,  apathy,  and  similar  aberrations  of  the  mental 
state. 

An  ataxic  gait  may  be  present  (L .  B  r  u  n s  '  s  frontal  ataxia) ,  with  weakness 
or  paresis  of  the  trunk  muscles.  These  are  due  to  a  lesion  of  the  tnmk  center 
in  posterior  portions  of  the  first  frontal  convolution.  Encroachment  on  the 
motor  area  by  the  growth  of  a  tumor  will  cause  temporary  monospasm  and 
monoplegia,  and  growth  in  the  direction  of  the  base  causes  symptoms  of  loss 
of  smell  (anosmia),  disturbances  of  vision,  optic  nerve  atrophy,  exophthalmos, 
etc.     Choked  disc  is  a  later  manifestation.     Hysteric  con\ailsions  or  genuine 


THE    BRAIN  469 

epilepsy  may  develop.  Finally,  there  may  be  tiirniii<i;  of  the  head  and  eyes 
toward  the  opposite  side.  The  presence  of  motor  aphasia  in  a  right-handed 
person  indicates  that  the  lesion  is  situated  in  the  speech  region.  This  consists 
of  the  posterior  half  of  the  third  (Broca's)  convolution,  the  island  of  Reil,  and  the 
first  temporal  convolution,  includuig  the  cortex  of  the  fissure  of  Sylvius.  The 
same  symptoms  occurring  in  a  left-handed  person  show  the  lesion  to  be  similarly 
situated  on  the  right  side.  Halting  speech  (bradyphasia)  and  fraitless 
whispering  efforts  (toneless  motions  of  the  lips)  are  characteristic  symptoms. 
To  these  may  be  added  inability  to  write  correctly  (agraphia)  and  word 
deafness  or  the  inability  to  understand  spoken  words  (sensory  aphasia). 
Motor  aphasia  and  sensory  aphasia  may  be  combined.  Aii  absence  of  aphasic 
symptoms,  however,  does  not  necessarily  exclude  lesion  on  the  left  side.  On 
the  other  hand,  aphasia  may  be  an  accompaniment  of  a  lesion  in  the  motor  area. 

The  Occipital  Lobe. — Lesions  of  this  region  are  always  accompanied 
by  symptoms  referable  to  disturbances  of  the  visual  center  situated  in  the 
cortex  of  the  calcarine  fissure  of  the  median  surface  of  the  occipital  lobe.  The 
most  important  of  these  is  that  which  causes  the  loss  of  the  power  of  vision  of 
the  lateral  half  of  the  visual  field  of  each  eye  (hemianopia) .  Though  the  focal 
lesion  may  occupy  but  one  side,  both  eyes  are  affected.  The  inner  (nasal) 
half  of  one  visual  field  and  the  outer  (temporal)  half  of  the  other  visual  field 
are  affected  (homonymous  hemianopia).  Hallucinations  of  ^dsion  and 
flashes  before  the  eyes  are  present.  Optic  aphasia  and  alexia  may  result  from 
tumors  seated  in  the  medullary  portion  of  the  left  occipital  lobe,  causing 
disturbances  of  the  association  tracts  betAveen  the  visual  center  and  the  speech 
center. 

Tumors  of  the  corpus  callosum  are  rare  and  present  but  few  general 
symptoms.  In  cases  of  close  approximation  or  growth  mto  the  central  convo- 
lution there  may  be  primary  paraparesis.  Grave  mtellectual  disturbances 
may  be  due  to  interruption  of  important  association  tracts. 

The  center  of  hearing  is  situated  in  the  upper  convolution  of  the  tem- 
poral lobe,  the  center  of  each  side  serving  for  both  ears.  Lesions  in  this 
region  give  rise  to  temporar}^  disturbances  of  hearing.  Only  lesions  of  both 
sides  give  rise  to  permanent  deafness.  Irritations  of  one  center  give  rise  to 
buzzing,  rumbling,  and  ringing  sounds  in  the  opposite  ear. 

The  sense  of  smell  is  probably  situated  in  the  uncinate  gyrus.  Hallucina- 
tions of  smell  have  been  observed  in  connection  AAith  lesions  in  this  region. 

Lesions  of  the  central  ganglia  (corpus  striatum  and  optic  thalamus) 
occur  without  symptoms  of  localized  disease  unless  the  internal  capsule  is 
affected,  when  disturbances  of  the  fibers  of  the  pyramidal  tract  are  present, 
giving  rise  to  hemichorea,  heixdathetosis,  tremor,  contralateral  convulsions, 
monoplegia,  and  hemiplegia.  In  lesions  of  the  posterior  region  of  the  internal 
capsule  hemianesthesia  is  present.  Lesions  of  the  posterior  section  of  the  optic 
thalamus  cause  hemianopia. 

Corpora  Quadrigemina. — -Tumors  in  this  region  cause  disturbances  of 
pupil  reaction  and  the  motility  of  the  globe  by  interfering  with  the  function  of 
the  oculomotor  or  third  nerve.  These  are  not  usually  symmetric  nor  of  equal 
severity.  As  a  rule,  the  abducens  escapes;  it  may,  however,  give  the  first 
symptoms.  Later  there  occur  ataxic  symptoms,  with  incoordination  in  stand- 
ing and  walking,  and  of  the  movements  of  the  arm.    Tremor  of  the  extremities 


470  THE  SURGERY  OF  THE  HEAD 

on  the  opposite  side  have  been  noted.  These  s^-mptoms  are  also  present  in 
tumors  of  the  pineal  gland,  but  the  trochlear  and  abducens  paresis  is  more 
marked. 

Tumors  of  the  Pons. — A  pons  symptom  usually  deemed  characteristic  is 
conjugate  paralysis  of  the  lateral  recti  of  the  eye.  The  external  rectus  of  one 
side  and  the  internal  rectus  of  the  other  are  involved.  As  a  result  the  patient 
cannot  move  the  eyes  beyond  the  median  line  toward  the  side  where  the  tumor 
is  situated.  Owing  to  the  close  proximity  of  the  tracts  for  both  sides  of  the 
body,  bilateral  manifestations,  both  motor  and  sensory,  are  easily  produced; 
alternating  and  combined  paralyses  of  the  facial,  abducens,  or  trigeminus  nerve 
on  the  side  of  the  tumor,  and  paralysis  of  the  extremities  on  the  opposite  side 
of  the  body  may  be  present.  Paralysis  of  the  recti  of  both  sides  (bilateral  conju- 
gate paralysis)  occurs.  The  eyes  cannot  be  moved  to  the  right  or  left,  though 
convergent  and  upward  and  downward  movements  remain  unaffected.  Tliere 
is  paresis  of  the  facial,  abducens,  and  trigeminus  nerves,  and  paraplegia  of  the 
extremities;  anesthesia,  ataxia,  tremor, and  disturbances  of  speech,  mastication, 
and  deglutition  are  present.  When  the  growth  is  toward  the  base,  pressure  on 
the  auditory  nerve  causes  disturbances  of  hearing.  When  in  an  upward  direc- 
tion, it  causes  cerebellar  symptoms;  and  when  backward,  symptoms  arising 
from  the  medulla  oblongata. 

Medulla  Oblongata. — Opportunities  for  the  observation  of  bulbar  mani- 
festations of  focal  injuries  are  not  frequent ;  with  the  involvement  of  the  respira- 
tory and  circulatory  centers  these  lesions  prove  rapidly  fatal.  Tumors  of  this 
region  are  followed  by  paralysis  in  the  area  of  distribution  of  the  glossopharyn- 
geal, pneumogastric,  spinal  accessory,  and  hypoglossal  nerves.  Paralysis  of 
the  pharynx  and  velum,  disturbances  of  deglutition  and  speech,  aphonia, 
slow  pulse,  followed  later  on  by  rapid  pulse,  Cheyne-Stokes  respirations,  and 
paresis  and  atrophy  of  the  tongue,  together  with  vomiting,  all  go  to  make  up  a 
characteristic  clinical  picture.  Most  of  the  symptoms  are  bilateral.  Death 
often  takes  place  suddenly.  Cases  occur  in  which  all  symptoms  are  absent  for  a 
considerable  time.  This  is  specially  true  of  cysts  and  obstructions  in  the 
aciuaeductus  Sylvii  with  resulting  accumulation  of  fluid  in  the  fourth  ventricle 
(internal  hydrocephalus).  With  the  occurrence  of  the  latter,  marked 
symptoms  of  brain  pressure  supervene.  Diabetes  mellitus  is  sometimes  present. 
Convulsions  of  a  hysteric  character  are  frequently  observed.  Choked  disc  is 
rare. 

Lesions  of  the  Base. — The  symptoms  arising  from  lesions  at  the  base 
vary  according  to  their  location.  Those  in  the  anterior  fossa  cause  unilateral 
loss  of  the  sense  of  smell  (anosmia),  unilateral  amblyopia,  atrophy  of  the  optic 
nerve  on  the  same  side,  and  paresthesia  in  the  first  branch  of  the  trigeminal. 
Symptoms  arising  from  pressure  on  the  frontal  lobe  or  involvement  of  it  follow 
extension  of  the  growth  of  a  tumor.  This,  occurring  on  the  left  side,  leads  to 
disturbances  of  speech.  Lesions  of  the  middle  fossa,  particularly  those  medi- 
anly  situated  (optic  chiasm,  sella  turcica,  and  hypophysis  cerebri),  give  rise  to 
the  most  striking  symptoms. 

Here  arise  characteristic  and  typic  visual  disturbances.  Dimness  of  vision 
(amblyopia),  with  blindness  of  the  external  half  of  the  visual  field  (temporal 
hemianopia),  and,  later,  atrophy  of  the  optic  nerve  with  amaurosis;  paralysis 
of  the  muscles  of  the  eye,  particularly  of  the  oculomotor,  followed  by  ptosis; 


THE    BRAIN  471 

diabetes  mellitus,  poh-dipsia,  and  polyuria  are  sometimes  present.  Hyper- 
trophic disturbances  of  the  hypophysis  are  followed  by  enormous  increase  in 
size  of  different  portions  of  the  body,  particularly  in  the  facial  region,  and  hands 
and  feet  (acromegaly).  Tumors  laterally  situated  produce  pressure  on  the 
fifth  nerve  and  Gasserian  ganglion,  with  extremely  severe  neuralgia  in  all  of 
the  branches,  and  paresthesia.  Neuropathic  keratitis  occurs,  weakness  and 
atroph}'  of  the  muscles  of  mastication  are  present.  The  tumor  may  increase 
sufficiently  in  size  to  cause  symptoms  in  the  frontal  and  temporal  lobes  and 
in  the  crus  cerebri.  Choked  disc  is  sometimes  present.  Lesions  of  the  pos- 
terior fossa  cause  symptoms  referable  to  important  nerve-trunks  (fifth  to 
twelfth),  the  pons,  and  the  medulla  oblongata.  In  the  case  of  neoplasms  the 
symptoms  are  first  unilateral  and  then  bilateral.  It  is  almost  impossible  to 
differentiate  new  growths  situated  at  the  base  from  those  of  the  cerebellum 
and  crus  cerebri. 

Tumors  springing  from  the  dura  mater,  pia  mater,  and  osseous  structures 
at  the  base  are  accompanied  by  intense  pain  and  by  a  tendency  to  perforate 
externally.  Aneurisms  of  the  internal  carotid,  basilar,  median,  and  posterior 
cerebral  arteries  give  rise  to  basilar  symptoms.  A  bruit,  synchronous  with 
the  pulse,  may  sometimes  be  obtained  on  auscultation  in  cases  of  aneurisms 
and  highly  vascular  tumors. 

Neoplasms  superficially  situated  (those  originating  in  the  cortex,  meninges, 
or  bones  of  the  skull),  with  their  tendency  to  grow  externally,  give  rise  to 
thinning  of  the  adjacent  bone  by  erosion  or  osteoporosis.  Percussion  may 
cause  pain  in  a  circumscribed  area  and  elicit  a  tympanitic  note  and  cracked  pot 
sound.  In  the  thin  skulls  of  children  and  the  aged  these  symptoms  are  without 
value.  With  advance  in  the  growth  of  the  tumor  and  continued  erosion  of  the 
skull,  perforation  of  the  latter  finally  takes  place  externally,  causing  local  edema 
of  the  scalp  and  sometimes  the  appearance  of  a  soft  fluctuating  swelling.  In 
sarcomas  of  the  base  of  the  skull  the  rupture  usually  takes  place  into  the 
nasopharynx.  Malignant  growths  of  endocranial  origin  rarely  lead  to  metas- 
tases. 

SURGICAL  EPILEPSY 

Epilepsy  sometimes  follows  cranial  and  other  injuries.  It  may  be  due  (1) 
to  peripheral  nerve  irritation  either  arising  in  a  scar  in  the  soft  parts  covering 
the  skull  or  following  an  injury  in  the  neighborhood  of  one  of  the  large  nerve- 
trunks  of  an  extremity,  particularly  the  sciatic  nerve  (reflex  epilepsy);  (2)  to 
changes  in  the  bones  of  the  skull  or  in  the  dura  (exostoses,  adhesions,  etc.); 
(3)  to  the  effects  of  injuries  of  the  cortex. 

In  cases  resulting  from  peripheral  nerve  irritation  the  irritating  influences 
start  from  the  scar;  if  this  is  excised  before  the  so-called  "convulsive  state" 
of  the  brain  has  been  established  by  repeated  attacks,  provided  hereditary 
influences  can  be  excluded,  a  cure  may  be  hoped  for.  Otherwise  the  condition 
is  a  permanent  one,  that  is  to  say,  slight  causes  will  produce  the  seizures,  these 
occurring  with  increasing  f  requeue  v. 

Scars  of  the  scalp  are  the  most  frequent  cause  of  surgical  epilepsy.  These 
are  usually  sensitive  to  pressure,  which  may  bring  on  an  attack.  They  may 
have  been  the  previous  seat  or  starting-point  of  neuralgic  pains.  The  site  of 
healed  fractures  of  the  skull,  not  necessarily  those  that  are  depressed,  may 


472  THE  SURGERY  OF  THE  HEAD 

behave  in  like  manner.  Healing  at  the  site  of  a  bone  defect  of  the  skull  is  quite 
as  likely  to  give  rise  to  surgical  epilepsy  as  that  of  an  old  depressed  fracture. 

Changes  in  the  cerebral  cortex  resulting  from  changes  in  tlio  motor  area 
or  from  diseased  conditions  of  this  area  produce  epileps}'  (cortical  or  Jack- 
sonian  epilepsy).  The  essential  feature  of  a  convulsive  seizure  originating 
in  cortical  epilepsy  is  its  occurrence  on  the  side  opposite  that  of  the  seat  of  the 
irritation.  The  sequences  of  craidal  injuries  not  involving  the  cortex  alone,  as 
well  as  surgical  epilejDS}"  from  other  causes,  give  rise  to  general  con^adsions. 

Surgical  epilepsy  of  a  reflex  character  is  never  the  result  of  a  recent  wound. 
Its  appearance  is  always  delayed  until  cicatrization  is  complete,  and  it  may 
follow  years  afterward.  In  cases  in  which  epileptiform  convulsions  occur 
immediately  after  or  soon  after  the  reception  of  a  cranial  injury,  these  are  due 
to  injuries  of  the  central  cortex  or  to  the  pressure  of  bone  splinters  or  other 
foreign  bodies. 

Treatment. — Operative  treatment,  to  be  of  any  avail,  should  be  resorted 
to  before  changes  in  the  brain  occur.  Removal  of  the  scar  is  the  first  step  and 
may  suffice.  This  failing,  the  skull  should  be  opened  by  an  osteoplastic  resec- 
tion, and  if  nothing  abnormal  is  found  (the  presence  of  a  cyst,  etc.),  the  bone 
flap  is  to  be  replaced  after  a  finger's-breadth  is  removed  from  its  circumference, 
the  relief  of  intracranial  pressure  thereby  being  provided  for  (Kocher). 
Lumbar  puncture,  puncture  of  the  ventricles,  and  even  drainage  of  the  ven- 
tricles have  also  been  recommended  with  the  same  aim  in  view.  In  cases 
occurring  in  connection  with  a  bony  defect  in  the  skull  good  results  have  been 
obtained  by  osteoplastic  procedures  designed  to  cover  these  in  (B  e  r  g  m  a  n  n). 
Resection  of  diseased  portions  (H  o  r  s  1  e  y  's  excision  of  a  motor  center)  has 
been  performed,  but  with  widely  varying  results  in  the  hands  of  different  oper- 
ators. On  the  theory  that  the  epileptic  attacks  are  due  to  vasomotor  spasm 
Alexander  suggested  the  removal  of  the  upper  cervical  sympathetic 
ganglion  (cervical  sympathectomy,  see  page  640).  Jonnescu's  experi- 
ence in  the  removal  of  all  three  of  the  cervical  sympathetic  ganglia  entitles  the 
operation  to  further  trial. 

ENCEPHALOCELE 

It  is  impracticable  to  differentiate  congenital  encephalocele,  meningocele, 
and  meningoencephalocele.  The  bony  covering  develops  but  incompletely 
over  the  brain;  the  latter,  in  some  instances,  is  arrested  in  its  development. 
The  tumor  is  found  in  the  middle  frontal  region  or  glabella ;  behind  the  mastoid 
process;  in  the  occipital  region;  in  the  cervical  region ;  finally,  a  ver}' rare  form 
is  found  in  the  fauces,  passing  down  in  a  bony  fissure  between  the  ethmoid  and 
the  sphenoid  bone.  These  locations  correspond  to  the  locations  of  the  ventricles 
from  which  the  tumors  develop.  The  tumors  are  not  found  in  connection  with 
the  fontanels.  The  occipital  encephalocele  is  the  most  frequently  observed; 
the  mastoid  is  very  rarely  seen.  That  which  occurs  in  the  frontal  region  is 
usually  very  small,  rarely  exceeding  a  hazelnut  in  size. 

The  diagnosis  of  congenital  encephalocele  is  based  on  its  location  and 
history.  Tumors  of  this  class  are  most  liable  to  be  confounded  with  dermoid 
cysts. 

Treatment  should  not  be  instituted  as  long  as  there  is  no  tendency  for  the 
tumor  to  increase  in  size.     More  than  one  life  has  been  sacrificed  in  the  attempt 


THE    BRAIN  473 

to  deal  surgically  with  these  tumors.  Where,  however,  the  coverings  become 
ver}-  thin  from  growth  of  the  tumor  and  threaten  perforation,  aseptic  aspiration 
of  a  given  quantity,  perhaps  less  than  a  dram,  followed  by  the  injection  of  an 
equal  quantity  of  Lugol's  solution,  may  be  tried.  The  needle  should  not 
be  introduced  directly  through  the  thm  coverings,  but  at  a  distance  from  the 
base,  in  the  healthy  scalp.  The  aspiration  and  injection  may  be  repeated  once  a 
week.  This  faihng,  extirpation  by  an  elliptic  incision  at  the  base  and  accurate 
coaptation  and  suturing  may  be  resorted  to.  In  the  large  pedunculated  en- 
cephalocele  of  the  newborn  a  double  thread,  carried  through  the  pedicle  and  tied 
on  each  side,  followed  by  removal  of  the  tiitaor  and  suture  of  the  gap,  has 
had  favorable  results  (B.  Flothmann).  In  extirpation  of  the  tumor  failure 
of  union  results  fatally,  ventricular  fluid  continuing  to  flow  from  the  gap  until 
the  end.  In  the  occasional  occurrence  of  an  encephalocele  \\dth  a  small  pedicle 
there  is  a  great  temptation  to  encircle  the  same  with  a  ligature.  Usually, 
however,  the  gangrenous  inflammation  which  results  passes  beyond  the  site  of 
ligation  and  death  follows. 

HYDROCEPHALUS 

The  fluid  in  hydrocephalus  ma}-  be  situated  m  the  cerebral  membranes  or 
inclosed  in  the  cavity  of  the  ventricles  (external  and  internal  hydrocephalus). 
In  the  majority  of  cases  the  latter  condition  obtains.  Hydrocephalus  usuaUy 
has  its  origin  at  birth,  and  contmues  to  develop;  postnatal  origin  is  rare. 
Separation  of  the  sutures,  attenuation  of  the  bones,  and  enlargement  of  the 
fontanels  are  the  salient  pathologic  features  in  the  beginnmg.  In  the  course 
of  the  disease  nuclei  of  bone  are  found,  th^se  representing  an  attempt  at  the 
formation  of  the  AVormian  bones.  Rachitis  is  to  be  considered  as  favoring  the 
development  of  the  disease,  rather  than  as  originating  it,  though  coexistence  of 
hydrocephalus  and  rachitis  is  of  frequent  occurrence. 

Internal  treatment  is  useless.  Compression  by  bandages  has  not  been 
followed  by  gratifying  results. 

Operative  treatment  should  always  be  tried  in  severe  cases  of  a  progressive 
character  that  menace  the  patient's  life.  The  question  of  operating  m  cases  m 
which  life  is  not  threatened,  but  in  which  progressive  idiocy  is  manifest,  is  still 
sub  jiidice.  Opinions  differ  as  to  the  justifiabilit}'  of  interfering  under  these 
circumstances.  The  grave  risks  which  are  nm,  whether  the  indication  is  vital 
or  psychopathic,  are  such  as  to  cause  the  surgeon  to  hesitate  before  interfering. 

Puncture  may  be  performed  either  at  the  site  of  one  of  the  sutures  (the 
sagittal  suture  being  avoided  on  account  of  the  proximity  of  the  longitudinal 
sinus)  or  through  the  orbital  ^'ault  (L  a  n  g  e  n  b  e  c  k) .  The  latter  situa- 
tion is  the  preferable  one,  both  because  of  the  thmness  of  the  roof  of  the  orbit, 
and  because  one  of  the  most  dependent  portions  of  the  ventricular  system  is 
reached  from  this  point.  Less  septic  material  is  likely  to  be  carried  m  with  the 
trocar  than  if  the  skin  is  punctured,  and  the  eyelid  closes  over  the  opening, 
assisting  in  protecting  the  latter  from  subsequent  infection.  The  upper  eyelid 
is  raised,  the  trocar  is  passed  through  the  retrotarsal  fold,  and  ^dth  a  firm 
thrust  is  made  to  perforate  the  thin  orbital  plate.  The  puncture  must  be 
repeated  several  times;  but  little  fluid  is  obtamed  at  each  puncture,  owing  to 
the  inelasticity  of  the  cranial  walls  and  the  desirability  of  not  permitting  air 
to  enter.     Aspiration  seems  to  offer  but  slight  advantage. 


474  THE  SURGERY  OF  THE  HEAD 


THE  SOFT  PARTS  OF  THE  FACIAL  REGION 

Injuries  of  the  Facial  Region. — Wounds  of  the  face,  owing  to  the 
vascularity  of  the  parts,  bleed  freely.  With  the  exception  of  some  of  the  larger 
branches  of  the  facial  artery,  however,  the  application  of  a  ligature  is  seldom 
required.  This  same  vascularity,  also,  explains  the  almost  invariable  oc- 
currence of  healing  by  first  intention  noticeable  in  wounds  in  this  region.  Even 
in  tissues  much  lacerated  and  contused,  sloughing  is  a  rare  circumstance. 
Nature's  efforts  are  frec^uently  so  successful  in  filling  up  defects  that  plastic 
procedures  are  best  deferred  until  complete  cicatrization  takes  place. 

Cicatricial  ectropion  of  the  eyelids  and  lips  occurs  from  burning  accidents. 
In  case  of  the  latter,  the  surgeon  should  never  fail  to  warn  the  patient  or  his 
friends  of  the  probability  of  such  an  occurrence.  The  burns  from  hot  water, 
caustic  liciuids,  and  chemic  substances  driven  against  the  face  in  laboratory 
accidents  are  usually  deeper  than  at  first  appears  and  frequently  involve  an 
unfavorable  prognosis,  as  far  as  the  cosmetic  effect  and  the  function  of  the  parts 
are  concerned.  In  the  case  of  the  lower  lip  the  saliva  trickles  away  and  the 
formation  of  labial  sounds  is  interfered  -with.  Ectropion  of  the  e}'elids  permits 
the  tears  to  flow  over  the  face  and  the  globe  of  the  eye  suffers  in  consequence. 
Extensive  formation  of  cicatricial  tissue  at  the  lateral  aspects  of  the  cheeks 
embarrasses  the  movements  of  the  inferior  maxilla.  Operative  interference 
is  here  demanded  (see  page  531,  Cicatricial  Lockjaw). 

The  presence  of  powder  grains  in  the  skin  of  the  face  involves  considerable 
disfigurement.  When  recent,  the  greater  portion  of  them  can  be  removed  by 
vigorously  scrubbing  the  face,  under  an  anesthetic,  by  means  of  a  coarse  and 
stiff  hand-brush  (Richardson).  A  cataract  needle  applied  to  each  powder 
grain,  if  the  case  is  not  seen  until  late,  will  remove  these  in  the  course  of  time, 
though  the  process  is  a  tedious  one.  The  prolonged  application  of  a  solution 
of  mercuric  chlorid  is  said  to  facilitate  the  extraction  (H  e  b  r  a). 

Simultaneous  wounds  of  the  skin  and  mucous  membrane  require  separate 
suture  of  these  structures.  This  is  particularly  true  of  the  eyelids.  Perforat- 
ing wounds  of  the  oral  cavity,  if  permitted  to  cicatrize,  leave  fistulous  openings 
through  which  liquids  escape,  as  well  as  mucus  and  saliva.  Stenson's  duct 
may  be  involved  in  the  injury,  and  the  parotid  secretion  poured  on  the  outside 
of  the  face  (see  page  587,  Salivary  Fistula). 

Traumatic  Inflammation. — While  the  extreme  vascularity  of  the  soft 
parts  in  the  facial  region  would  tend  to  favor  the  extension  of  septic  processes, 
it  is  nevertheless  true  that  these  are  of  rather  infrequent  occurrence.  This  is 
mainly  due  to  the  peculiar  arrangement  of  the  subcutaneous  connective  tissue 
which  passes  directly  at  right  angles  to  the  surface  to  embrace  the  subcutaneous 
muscles.  Though  wounds  in  the  neighborhood  of  these  muscles  gape  widely, 
yet  the  peculiar  arrangement  of  the  connective-tissue  fibers  prevents  propaga- 
tion of  septic  inflammatory  processes.  In  other  parts,  however,  as,  for  instance, 
in  the  eyelids,  the  fibers  of  the  connective  tissue  are  arranged  paraflel  to  the 
fibers  of  the  orbicularis  palpebrarvim,  and  phlegmonous  inflammation  is  more 
likely  to  occur.  Destruction  of  tissue  here  may  give  rise  to  cicatricial  shorten- 
ing of  the  integumentary  surface  of  the  eyelid  and  conseciuent  ectropion. 
Extension  of  the  septic  process  through  the  medium  of  the  palpebral  fascia 


THE  SOFT  PARTS  OF  THE  FACIAL  REGION  475 

and  along  the  muscles  of  the  globes  or  sheaths  of  the  nerves  into  the  mass  of 
fat  behind  the  globe  itself,  and  thence  through  the  superior  or  inferior  orljital 
fissure  to  the  brain,  may  occur. 

The  most  characteristic  symptom  of  septic  inflammation  about  the  face  is 
extensive  edematous  swelling  of  the  parts  involved.     This  is  due  partly  to 
venous  and  Ivmphatic  congestion  and  partly  to  serous  infiltration.     Erysipelas 
infection  likewise  produces  edema.     The  occurrence  of  erysipelas  m  the  face 
may  lead  to  its  extension  to  the  scalp  and  give  rise  to  the  peculiar  dangers 
which  result  from  the  presence  of  this  infection  in  that  region.     Septic  thrombi 
in  the  facial  and  orbital  veins  may  cause  metastatic  pyemia.     Taking  it  all 
in  all.  therefore,  though  this  region  in  all  its  parts  is  not  particularly  prone  to 
inflanmiatorv  septic  processes,  yet  in  locahties  where  these  do  occur,  serious 
results  mav  'follow.     To  add  to  the  difficulties,  the  presence  of  the  nares  and 
mouth  somewhat  embarrasses  the  efficient  application  of  antiseptic  dressings. 
The  use  of  collodion  mixed  with  subiodid  of  bismuth  or  iodoform  (K  ii  s  t  e  r), 
penciled  over  the  wound  edges  after  coaptation  of  these,  is  here  very  useful. 
Nontraumatic  Inflammation.— Eczematous  conditions  of  the  skm  of 
the  face  in  children  are  of  interest  to  the  surgeon  principally  from  the  lymphatic 
glandular  involvement  near  the  angle  of  the  jaw.  which  is  likely  to  follow.  _ 
In  addition  to  ordinary-  bacterial  mfection.  the  integument  of  the  face  is 
liable,  through  the  open  foUicles.  to  invasion  of  the  so-cahed  thread  fungi.     The 
special  varieties  of  inflammation  caused  by  the  presence  of  these  vegetable 
ectoparasites  may  be  simply  mentioned;  they  belong  particularly  to  the  domain 
of  dermatologv : '  favus ;    sycosis  or  mentagra ;  blepharadenitis  or  inflammation 
at  the  ciliary'  margin.     The  inflammatory'  conditions  arismg  from  these  are 
so  slight  compared  with  those  which  arise  from  common  bacterial  mfection  as 
to  amount  to  scarcely  more  than  an  irritation. 

Acne  pustulosa'is  the  least  important  of  the  acute  inflammations  of  the 
sebaceous  glands.  The  small  pustules  may,  however,  lead  to  deeper  infection, 
in  which  case  a  furuncle  develops.  Hordeolum  or  sty  is  an  inflammation  of 
the  sebaceous  glands  at  the  tarsal  margin.  Carbuncle  develops  most  readily 
at  the  lips  and  cheeks,  the  short  connective-tissue  fibers  in  these  locahties  favor- 
ing constriction  of  the  vessels  and  early  sloughing  in  the  presence  of  specific 
mtcroorganisms.  Carbuncle  m  these  situations  is  a  very  serious  affection, 
er^-sipelatous  infection  reacUly  occurring  and  spreading.  Pyemia  from  throm- 
bosis of  the  facial  vein  may  occur.  Such  energetic  measures  as  total  excision 
of  the  carbuncle  in  severe  cases  are  here  justifiable,  despite  the  possibilities  of 
subsequent  cicatricial  deformity.  Even  in  mild  cases  nothing  short  of  early 
crucial  incision  and  vigorous  curetting  will  suffice. 

Noma.— This  is  a  peculiar  affection  of  the  mucous  membrane  of  the  cheek. 
A  diphtheritic  inflammation  of  the  mucous  membrane  of  the  cheek  is  followed 
by  gangrene.  A  smaU  black  spot  first  appears  which  mcreases  rapidly  m  size. 
General  mfection  mav  follow,  or  the  sloughmg  mass  may  be  cast  off.  cicatriza- 
tion takmg  place  with  a  peculiar  star-shaped  scar.  Considerable  deformity  of 
the  angle  of  the  mouth  occurs,  the  latter  being  dra^ii  outward  and  upward  ^^ith 
exposure  of  the  teeth.  FLxation  of  the  jaw  from  cicatricial  lockjaw  may  also 
occur.     Operative  interference  is  here  necessary  m  order  to  restore  the  function 

of  the  parts. 

Various  causes  have  been  assigned  for  noma .     From  the  fact  that  it  develops 


476  THE  SURGERY  OF  THE  HEAD 

at  first  at  the  orifices  of  Stenson's  duct,  it  has  been  thought  that  mercurial 
sahvation,  if  it  does  not  actually  produce  the  disease,  at  least  predisposes  to  it. 
This  circumstance,  at  least,  suggests  that  care  should  be  exercised  in  the  use  of 
mercurials,  particularly  in  children  suffermg  from  scarlathia,  in  the  course  of 
which  disease  noma  is  particularly  liable  to  develop.  A  microorganism  that 
seems  morphologically  the  same  as  the  K  1  e  b  s  -  L  o  f  f  1  e  r  bacillus  of 
diphtheria  has  been  identified  in  these  cases.  The  treatment  consists  in  freely 
applyuig  the  thermocautery  to  the  gangrenous  area  and  packmg  the  resultmg 
cavity  with  freciuently  changed  compresses  wet  with  solution  of  hydrogen 
dioxid. 

Facial  Erysipelas. — This  disease  was  formerly  relegated  to  the  domain 
of  mternal  medicine  under  the  belief  that  it  was  an  idiopathic  affection. 
The  disease,  ho-\^'ever,  depends  on  the  presence  of  a  specific  microorganism 
(see  pages  27  and  178)  which  finds  its  entrance  into  the  depths  of  the  skm 
probably  through  some  slight  fissure  or  excoriation,  at  the  site  of  an  acne 
pustule,  or  through  the  follicular  openings  on  the  nose,  which,  m  this  locality 
are  unusually  large.  Its  course  is  similar  to  that  obser^-ed  in  the  case  of 
Avounds,  and  the  same  treatment  is  applicable. 

Herpes  labialis  is  without  special  mterest  to  the  surgeon.  Herpes  rhag- 
ades  is  that  variety  of  herpes  which  appears  at  the  angles  of  the  mouth  and  is 
sometimes  a  symptom  of  general  syphilitic  infection. 

Lupus  as  it  attacks  the  facial  region  appears  by  preference  on  the  cheeks  and 
lips,  though  it  may  attack  the  eyelids.  In  the  latter  situation,  it  is  usually  an 
extension  from  the  nose.  (For  Nasal  Lupus,  see  page  501.)  It  may  appear  in 
the  hypertrophic,  ulcerative,  or  exfoliative  form.  The  first  named  is  much 
rarer  on  the  cheek  than  on  the  nose  and  eyelids.  The  ulcerative  form 
occurs  more  commonly  on  the  cheek,  thence  extending  to  the  lips  and  region 
of  the  chm.  The  secretion  dries  on  the  ulcerated  surface,  forming  dark  and 
foul-looking  crusts.  The  ulceration  very  rarely  passes  to  a  depth  sufficient  to 
invade  the  fatty  structures  beneath ;  hence  invasion  of  the  cavity  of  the  mouth 
is  not  observed.  In  the  case  of  the  lips,  however,  the  entire  thickness  is  in- 
vaded, and  extension  to  the  gums  likewise  takes  place.  The  presence  of  a  less 
amount  of  fatty  tissue  and  the  preponderance  of  muscular  structure  in  the  lips 
accounts  for  the  greater  tendency  to  deep  and  destructive  ulceration  in  the 
latter  region,  as  compared  with  the  cheeks.  Primar}'  lupus  of  the  lips  is  rare, 
however;  its  occurrence  here  is  usually  the  result  of  extension  from  the  nose  or 
cheeks.  The  exfoliative  form  of  the  disease  may  extend  from  the  face  to  the 
region  of  the  neck.  It  likewise  occurs  as  an  independent  process  and  is  char- 
acterized b}'  its  disposition  to  extend  over  larger  areas  without  tending  to  pass 
deejDly  into  the  skin. 

In  the  treatment  of  lupus  radical  measures  are  indicated  m  the  severe 
forms.  These  include  excision  in  some  cases,  and  the  use  of  the  actual  cauter}' 
or  caustic  appHcations  m  others.  In  any  event,  destruction  of  the  lupus 
tissue  is  imperative.  When  excision  is  practised,  the  immediate  transplantation 
of  strips  of  skm  by  Thiersch's  method  (see  page  331)  gives  the  best 
results  (S  e  n  g  e  r) .  The  employment  of  skm  graftmg  after  the  manner  of 
R  e  V  e  r  d  i  n  also  gives  good  results.  In  cases  in  which  these  procedures  are 
not  applicable,  as,  for  instance,  where  the  entire  thickness  of  the  lip,  or  the  nose, 
is  destroyed,  plastic  operative  procedures  are  to  be  employed  (see  page  509) . 


thp:  soft  parts  of  the  facial  region  477 

It  has  been  observed   that,  after  the  transplantation  of  new  tissues  from  a 
distant  part,  hipus  tissue  which  has  been  left  behind  disappears. 

Microstoma  results  from  cicatricial  contraction  of  the  mouth  and  is  to  be 
treated  b}'  a  stomatoplastic  procedure  (see  page  493). 

TUMORS  OF  THE  CHEEKS,  LIPS,  AND  EYELIDS 

The  congenital  tumors  of  the  facial  region  include  capillary  angiomas 
and  pigmentary  nevi.  The  former  are  characterized  by  fiat  propagations  on 
the  surface,  or  subsequently  to  their  appearance  on  the  skin  they  may  develop 
within  the  deeper  structures  (parotid  gland,  etc.,  see  page  227).  Extirpation 
and  subsec[uent  plastic  operations  are  sometimes  reciuired. 

Pigmentary  nevi  and  more  rarely  warty  nevi  develop  at  the  margin  of  the 
mucous  membrane  of  the  lower  lip;  in  this  situation  they  sometimes  precede 
the  development  of  carcinoma. 

Congenital  hyperplasia  of  the  labial  substance  is  sometimes  observed. 
The  thickening  may  be  due  to  an  excessive  thickening  of  lymph-vessels 
(lymphangioma)  or  the  hyperplastic  condition  may  refer  more  to  the  mucous 
membrane,  becoming  visible  as  a  "double  lip"  during  the  act  of  laughing. 
Scrofulous  edema  of  the  lips  is  confined  to  the  upper  lip  and  is  usually 
associated  with  eczema,  chaps,  etc.  Compression  by  means  of  elastic  bandages 
is  the  best  treatment  (K  o  n  i  g) .  Mucous  cysts  from  retention  of  secretion  are 
rather  frequent.  They  are  thin  walled  and  vary  from  the  size  of  a  pea  to  that 
of  a  hazelnut. 

Lymphangiectatic  congenital  cysts  are  found  beneath  the  mucous  mem- 
brane of  the  cheek  ( V  o  1  k  m  a  n  n) .  A  mucous  cyst  is  to  be  distinguished 
from  the  cysticercus  cutis  sometimes  found  near  the  orifice  of  the  mouth; 
it  is  about  the  same  size  but  is  more  deeply  situated.  The  tissues  about  the 
latter  are  more  solidly  infiltrated  than  in  mucous  cysts.  Adenoma  of  the  lips 
is  rare. 

The  lips  are  very  rarely  the  seat  of  atheroma;  this  occurs,  however,  in  the 
cheek  and  e3'elids.  (See  page  235  for  Dermoids.)  Lipoma  originates  from 
the  deep  adipose  tissue  of  the  middle  of  the  cheek.  Fibroma  is  also  observed 
in  the  cheek. 

Leontiasis  is  a  hyperplasia  of  the  skin  of  the  face  in  which  the  skin  of  the 
cheek,  eyelids,  and  lips  hangs  down  in  long  folds;  the  disease  takes  its  name 
from  the  peculiar  appearance  of  the  patient.  It  corresponds  to  elephantiasis 
in  other  portions  of  the  body.  Ligation  of  the  common  carotid  arteries  has 
been  successfully  employed  for  its  cure  (C  a  r  n  o  c  h  a  n). 

Adenoma  of  the  sweat-glands  consists  of  a  flat  elevation  of  the  skin  and 
has  a  dark  red  appearance.  The  color  is  due  to  increased  proliferation  of  the 
vessels.  It  should  be  distinguished  from  the  hypertrophic  form  of  lupus ;  the 
latter  possesses  a  tendency  to  extend  not  present  in  the  former.  Its  relation 
to  carcinoma  has  been  demonstrated  (Konig).  It  selects  by  preference 
the  skin  at  the  junction  of  the  nose  and  cheek. 

Intraocular  sarcoma  may  affect  the  retina,  the  iris,  or  the  optic  nerve. 
The  first  named,  known  as  glioma,  occurs  exclusively  in  children  during  the 
first  four  years  of  life.  Both  retinas  are  affected  in  about  one-fifth  of  the  cases. 
The  symptoms  are  dilatation  of  the  pupil,  followed  by  complete  blindness. 


478 


THE    SURGERY    OF   THE    HEAD 


Fig.  248. — Rodent  Cancer  of  the  Face. 


As  the  tumor  increases  in  size  the  intraocular  structures  are  pushed  forward, 

pain  is  present  as  the  intraocular  tension  increases,  and  a  fungating  mass  makes 

its  appearance.     This  bleeds  easily  and  a  sanious  discharge  is  present.     There 

is  little  tendency  to  broad  dissemination, 
secondary  deposits,  as  a  rule,  being  con- 
fined to  the  brain,  the  lymphatic  glands, 
and  the  periosteum  of  the  orbit.  Extir- 
pation in  the  late  cases  is  followed  by  re- 
currence in  these  parts,  while  in  the 
early  cases  it  occurs  in  the  stump  of  the 
optic  nerve.  Intraocular  sarcomas  of 
adults  are  always  of  the  pigmented  type 
and  almost  without  exception  occur 
unilaterally.  They  appear,  as  a  rule, 
between  the  fortieth  and  the  sixtieth 
year  of  life.  Dissemination  is  the  rule, 
and  recurrence  almost  invariable,  even 
after  the  lapse  of  years.  The  brain  is 
very  rarely  involved,  and  adjacent  lymph- 
glands  are  almost  never  infected.  Death 
usually  takes  place  from  secondary  de- 
posits  in   important  organs.      Life  may 

be  prolonged,  however,  by  early  extirpation  of  the  globe. 

Rodent  Ulcer. — This  is  a  name  given  to  a  form  of  cancer  which  may 

attack  any  or  all  of  the  glandular  or  epithelial  structures  of  the  skin  of  the  facial 

region    (Fig.    248).     It    probably    arises 

in    the    sebaceous    glands    (Sutton). 

Though  its  favorite  location  is  the  face, 

it  may  occur  on  the  neck  or  pinna,  and 

is   occasionally  met  with  on  the  trunk. 

It  is  most  common  in  advanced  life,  but 

is  occasionally  seen  between  the  ages  of 

thirty  and    fifty.     It    is  observed   more 

freciuently  in  men  than  in  women. 

The  simple  nodule  which  heralds  its 

appearance    may    remain  stationary  for 

years,  when,  without  apparent  reason,  it 

may  break  dowm,  and  rapid  ulceration  of 

the  surrounding   parts  take    place  with- 
out regard  to  their  structure.     Once  the 

■  destructive  process  is  initiated,  it  is  never 

arrested    except    by    complete    excision, 

though  the  disease   may  last   for  years 

and  give  rise  to  no  pain  and  very  little 

discomfort  except  that  of  a  mental  char- 
acter   from    the    horrible    disfigurement 

which  it  occasions. 

Section  of  the  nodule  before  ulceration  sets  in  shows  this  to  be  made  up  of 

gland  ducts  filled  with  epithelium,  or  of  solid  cylinders.     Though  the  progres- 
sively destructive  course  of  the  disease  and  the  certainty  with  which  it  finally 


Fig.  249. — Epithelial  Carcinoma  of  the 
Cheek. 


THE    SOFT   PARTS    OF   THE    FACIAL    REGION  479 

causes  death,  stamp  it  a.s  of  a  malignant  nature,  yet  some  of  the  other  char- 
acteristic features  of  malignancy,  namel}^,  lymphatic  glandular  infection, 
dissemination,  and  raj^iid  growth,  are  absent. 

It  is  generally  found  on  the  cheek  and  ej'elids.  It  ma}-  extend  to  the  fore- 
hvad  and  involve  a  portion  of  the  scalp  (Fig.  248).  Sometimes  it  develops  on 
cicatrices  at  the  site  of  old  burns,  or  of  wounds,  or  of  lupus.  It  is  slow  of 
growth;  cicatrization  in  the  region  of  the  lips  and  eyelids  leads  to  ectropion  of 
these.  Other  forms  of  carcinoma  found  are  the  epithelial  variety,  which 
selects  the  lips,  particularly  the  lower  lip,  and  the  papillomatous.  The  latter  is 
characterized  by  proliferation  of  papillomatous  structure  and  attacks  the 
mucous  membrane  lining  the  cheek.  This  variety  is  to  be  distinguished 
from  syphilitic  mucous  patches;  carcinoma  in  general  in  these  regions  is 
to  be  differentiated  from  syphilis  and  lupus. 

Carcinoma  of  the  Lips.— This  is  most  frequently  observed  between  the 
thirty-fifth  and  the  sixtieth  year  and  shows  a  marked  preference  for  the  lower 
lip  in  men.  In  the  rare  cases  in  which  it  occurs  in  the  upper  lip  it  is  found  in 
both  sexes  in  about  ecjual  proportion.  The  submaxillary  h^mphatic  glands 
are  early  infected,  form  large  masses,  and  finally  implicate  the  skin.  Death 
takes  place  from  combined  septic  and  anemic  conditions,  hemorrhage,  or  septic 
pneumonia.  In  the  natural  history  of  the  disease  the  average  duration  of  life 
is  one  year. 

Carcinoma  of  the  lower  lip  affects  men  almost  exclusively.  In  62  cases 
only  one  was  found  in  a  woman  (Winiwarter).  Inhabitants  of  rural 
districts  are  said  to  be  more  frequently  attacked  than  the  residents  of  cities. 
Whether  or  not  smoking  is  the  cause  of  the  disease,  it  is  none  the  less  true  that 
persons  who  have  never  smoked  suffer  from  the  disease.  The  place  of  its 
occurrence  on  the  vermilion  border,  about  half-way  between  the  median  line 
and  the  oral  angle,  probably  first  suggested  its  name  of  "smoker's  cancer." 
An  epidermal  thickening  first  appears,  or  a  warty  excrescence  which  bleeds 
easily;  ulceration  soon  follows.  The  ulceration  usually  spreads,  first  in  a 
horizontal  direction,  and  toward  the  angle  of  the  mouth;  afterward  in  a  vertical 
direction.  Sometimes  the  ulceration  passes  in  a  downward  direction,  involving 
the  region  of  the  chin.  In  cases  of  long  duration  the  growth  may  reach  the 
angle  of  the  mouth,  pass  to  the  upper  lip,  and  finally  reach  the  other  angle  of 
the  mouth.  The  ulceration  has  a  characteristically  hardened  base  and  an 
infiltrated  edge.  The  disease  may  pass  to  the  mucous  membrane  of  the  mouth, 
cross  the  gingival  fold,  and  attack  the  mucous  membrane  of  the  gums. 

Glandular  Involvement. — The  lymphatics  from  the  lower  lip  empty  into 
the  lymphatic  glands  below  and  behind  the  angle  of  the  jaw;  occasionally  they 
comnmnicate  with  those  in  the  region  of  the  myoh3-oid  and  geniohyoid  muscles. 
■  The  first  named  situation  is  the  site  of  the  first  set  of  glands  concerned  in  secon- 
dary glandular  involvement  in  carcmoma  of  the  lower  lip.  They  are  best 
examined  by  passing  the  finger  between  the  tongue  and  the  jaw  and  crowding 
the  groups  of  glands  against  a  finger  of  the  other  hand  placed  on  the  outside. 
Glandular  invoh-ement  not  discoverable  b}-  ordinary  methods  of  examination 
can  be  made  out  in  this  manner. 

Diagnosis. — No  difficulty  is  encountered  in  diagnosing  carcinoma  of  the 
lower  lip.  The  only  disease  with  which  it  can  possibly  be  confounded  is  the 
initial  sclerosis  of  s}'philis  (hard  chancre).     In  individuals  below  thirty  years 


480 


THE    SURGERY    OF    THE    HEAD 


of  age  an  ulcer  ^ith  an  indurated  base  and  infiltrated  edge  may  be  a  hard 
chancre;  m  those  above  thirty,  it  is  almost  sure  to  be  carcmoma.  In  case  of 
doubt  a  course  of  mercurial  inunction  will  settle  the  question.  Valuable  time 
may  be  lost  in  this  way,  however,  and  it  were  better  to  extirpate  any  number 
of  suspicious  ulcerated  patches  on  the  lower  lip  than  to  err  m  the  other  direction 
and  by  delay  sacrifice  a  life. 

Carcinoma  of  the  Upper  Lip. — The  occurrence  of  tlie  disease  in  this 
situation  is  Acr}-  rare  (5.4  per  cent,  Loos),  excluding  the  carcinomas  which 
have  their  origm  m  tlie  lower  lip. 

Epithelial  carcmoma  is  the  variety  of  tlie  disease  met  hi  these  regions 
almost  exclusiveh'. 

The  Operative  Treatment  of  Carcinoma  of  the  Lip. — If  the  disease  is 
diagnosed  early,  a  simple  V-shaped  incision  extending  through  the  entire 
thickness  of  the  lip  and  carried  m  all  directions  well  beyond  the  limits  of  the 
disease  (one-quarter  of  an  mch  at  least)  will,  m  the  great  majority  of  cases,  effect 
a  permanent  cure  (Fig.  250) .  If  no  glandular  involvement  is  present,  so  simple 
is  this  operation  and  so  rapidly  is  it  accomplished,  that  even  an  anesthetic  is 

not  rec[uired,  or,  at  least,  cocain 
local  anesthesia  is  all  that  is  neces- 
sary. A  few  vigorous  strokes 
with  a  pair  of  stout  scissors  suf- 
fice for  the  extirpation.  The  lip 
should  be  grasped  firmh-  with 
the  thumb  and  forefinger  of  the 
left  hand,  the  fingers  of  an  assist- 
ant at  the  same  time  graspmg 
the  mouth  at  the  angle  in  order 
to  arrest  the  hemorrhage  from 
the  coronary  arteries.  Or,  a  nar- 
row bladed  scalpel  may  be  em- 
ployed, the  angle  of  the  V  being 
transfixed  and  the  incision  car- 
ried upward  through  the  border 
of  the  lip,  first  along  one  of  the  dotted  lines  shoT^'n  in  the  figure,  and  then 
along  the  other.  The  narro"v\ing  of  the  mouth  consecjuent  on  suturing  the 
gap  will  be  soon  compensated  for  by  changes  in  the  angles  of  the  mouth, 
these  becomhig  elevated  m  such  a  manner  that  the  relatively  increased  length 
of  the  upper  lip  is  m  time  partially  transferred  to  the  lower. 

As  in  harelip,  the  first  suture  is  to  be  applied  in  such  a  manner  as  to  arrest 
hemorrhage  from  the  vessels.  In  case  diflficulty  is  experienced  in  closmg  the 
gap,  the  tension  should  be  relieved  by  relaxation  incisions;  these,  however, 
are  rarely  necessary.  The  suturing  of  the  mucous  membrane  at  the  margin 
of  the  lip  should  be  done  carefully.  It  may  be  necessar\'  to  apply  separate 
sutures  to  the  mucous  membrane  lining  the  lip.  Alternate  tension  and  super- 
ficial or  approximation  sutures  are  to  be  applied.  A  dressing  of  iodoform 
or  subiodicl  of  bismuth  collodion  is  sufficient  protection  applied  along  the  Ime 
of  sutures.  The  mouth  should  be  washed  out  occasionally  with  either  a  boric 
acid  or  biborate  of  soda  solution,  particularl}'  after  taking  food.  (For  Cheilo- 
plasty,  see  page  482.) 


Fig.  250. — Cakcixoma  of  the  Lower  Lip. 

The  dotted  lines  show  the  direction  of  the  common  V 

shaped  incision  for  extirpation  of  the  growth. 


THE    SOFT    PARTS    OF    THE    FACIAL   REGION  481 

Not  only  should  enlarged  and  lionce  diseased  lymphatic  glands  be  sought 
on  the  corresponding  side  of  the  neck  during  the  operation,  but  on  the  opposite 
side  as  well.  On  no  account  should  they  be  looked  upon  as  inflammatory  in 
origin.  On  the  slightest  sign  of  a  recurrence  of  the  disease,  the  operative 
procedure  is  to  be  repeated.  A  slight  thickening  or  wartlike  appearance  in 
the  neighborhood  of  the  scar  should  receive  immediate  attention. 

It  is  surprising  to  what  extent  portions  of  the  lower  lip  can  be  repeatedly 
removed  and  yet  the  narrowed  oral  opening  regain  a  fairly  comfortable  size 
from  changes  which  occur  at  the  angles. 

In  cases  in  which  late  operations  are  performed  the  latter  may  necessitate 
resection  or  excision  of  the  lower  jaw  as  well.  The  involvement  of  the  bone 
may  result  from  an  extension  of  the  primary  focus  along  the  mucous  membrane 
to  the  ghigival  coverings,  and  thence  to  the  osseous  structure;  or  it  may  be 
due  to  an  extension  of  the  disease  from  secondary  involvement  of  the  glands 
lying  close  to  the  angle  of  the  jaw  in  the  neighborhood  of  the  facial  artery. 
These  latter  are  almost  invariably  involved,  even  early  in  the  disease.  The 
close  proximity  of  these  to  the  periosteum  leads  to  early  extension  to  the  latter 
and  thence  to  the  bone,  once  the  glands  are  affected. 

The  prognosis  in  late  operations  is  very  unfavorable.  Even  with  removal 
of  the  primary  focus  and  extirpation  of  all  apparently  diseased  glands,  the 
deeper  lymphatic  structures,  particularly  those  adjacent  to  the  cervical  spine, 
become  involved  to  an  extent  which  precludes  the  possibility  of  removal. 

Carcinoma  of  the  Cheek. — This  is  often  confounded  with  syphilitic 
ulcer.  It  is  sometimes  preceded  by  leukoplakia.  In  frequency  of  occurrence 
it  stands  midway  between  carcinoma  of  the  lips,  tongue,  and  floor  of  the  mouth, 
which  are  very  commonly  affected,  and  carcinoma  of  the  hard  and  the  soft 
palate,  which  are  comparatively  rarely  attacked.  It  occurs  more  frequently  in 
males,  and  particularly  in  those  who  smoke  or  chew  tobacco.  In  the  majority 
of  cases  the  disease  originates  in  the  cul-de-sac  between  the  gum  of  the  lower 
jaw  and  the  cheek,  whence  it  ascends  along  the  alveolar  process,  attacking  the 
gum  and  periosteum  and  the  buccal  mucosa  as  well.  It  may  commence  at  the 
angle  of  the  mouth.  The  submaxillary  lymphatic  glands  become  involved  early. 
The  cheek  is  soon  perforated  and  a  fistulous  opening  leading  into  the  cavity  of 
the  mouth  results.  The  submucous  tissues  are  infected  more  rapidly  than  the 
mucous  membrane.  Inflammatory  symptoms  sometimes  supervene;  subperi- 
osteal abscesses  may  develop  and  phlegmonous  and  erysipelatous  conditions 
are  not  infrequently  observed. 

The  prognosis  is  grave.  The  disease  runs  i-ts  course  rapidly  and  the  great 
majority  of  patients  come  to  the  surgeon  too  late  for  successful  operative 
interference.  In  advanced  cases  the  usual  yellow  hue  of  cancerous  cachexia 
is  replaced  by  a  peculiar  pallor,  which  constitutes  a  contraindication  to  opera- 
tion. 

Treatment. — Extirpation  is  the  only  resource.  This  must  include  the 
acljoinmg  bone  with  its  coverings.  The  incisions  commence  at  the  angle  of 
the  mouth,  radiating  from  this  point  backward,  so  as  to  include  all  the  affected 
tissues.  The  involved  glands  are  first  dissected  out,  the  dissection  going  ^ide 
of  these.  In  the  case  of  the  lower  cul-de-sac  the  inferior  maxilla  is  sawed 
through  in  front  near  the  median  line,  the  floor  of  the  mouth  detached,  and  the 
ascending  ramus  sawed  through.  The  jaw  is  now  drawn  forward  and  the 
32 


482 


THE    SURGERY    OF   THE    HEAD 


entire  thickness  of  the  cheek  extirpated  ^^■ith  the  tumor  and  bone  still  attached 
by  diA'idino;  the  pteryo;oid  and  remaining  attachments.  In  the  case  of  the 
upper  cul-de-sac  the  corresponding  half  of  the  upper  jaw  and  the  carcinomatous 
mass  must  be  removed.  In  closing  the  wound,  the  mucous  membrane  of  the 
floor  of  the  mouth  is  detached  up  to  the  tongue,  and  sutured  to  the  edge  of 
the  divided  mucous  membrane  of  the  cheek,  and  the  edges  of  the  skin  wound 
sutured.      The  after-treatment  is  the  same  as  in  carcinoma  of  the  tongue, 


Fig.  251. — Estlander's  Cheiloplastt. 
1.  A,  Portion  taken  from  upper  lip  and  cheek  to  fill  defect.     2.  The  parts  as  they  appear  after  suturing. 

namely,  frequent  irrigations  with  boric  acid  solutions,  spraying  with  hydrogen 
dioxid,  and  the  twice  daily  application  of  a  10  per  cent  solution  of  chlorid  of 
zinc. 

Carcinoma  of  the  Gum. — The  favorite  starting-place  for  cancer  of  the 
gum  is  the  mucous  membrane  covering  the  lower  alveolar  processes;  not  in- 
frequently the  site  of  a  carious  tooth  is  selected.  Early  infection  and  massive 
enlargement  of  the  glands  of  the  neck  occur.     Some  of  the  reported  cases  of 


Fig.  252. — Bruns's  Cheiloplasty. 
1.  Showing  the  lines  of  incision  for  the  removal  of  the  disease  and  supplying  the  defect.     2.  Sho^ong  the 

position  of  the  parts  after  suturing. 


primary  carcinoma  of  the  neck  were  in  all  probability  the  result  of  glandular 
infection  from  small  and  undiscovered  epithelioma  of  the  mouth  or  of  con- 
tiguous parts.  The  adjacent  bony  parts  are  invaded  to  an  extraordinary 
extent.  In  the  somewhat  rare  cases  in  which  the  disease  occurs  in  the  mucous 
membrane  of  the  alveolar  processes  of  the  upper  jaw,  the  antrum  is  opened 
and  the  disease  invades  its  cavity. 

Cheiloplasty. — In  cases  in  which  it  may  be  deemed  desirable  to  replace 


THE    SOFT   PARTS   OF   THE   FACIAL   REGION 


483 


the  lower  margin  of  the  lower  lip  immediately  after  an  operation  for  carcinoma, 
this  may  be  done  by  the  operation  devised  by  Estliinder  (Fig.  251).  A 
flap,  the  base  of  which  is  formed  at  the  upper  lip,  is  taken  from  the  cheek  and 
carried  down  to  assist  in  filling  up  the  gap  in  the  lower  lip.     If  care  is  exercised 


Fig.  253. — Langenbeck's  Cheiloplasty. 
1.  Lines  of  incision.     2.  Appearance  of  the  parts  after  suturing. 


in  shaping  the  flap,  it  will  contain  the  superior  coronary  artery,  which  will 
aid  in  its  nutrition. 

Special  operative  procedures  are  to  be  instituted  in  cases  in  which  the  disease 
is  more  extensively  distributed. 
When  the  entire  lower  lip  is  in- 
volved, the  plastic  procedure  of 
B  r  u  n  s  ,  in  which  the  defect  is 
supplied  from  the  cheek,  will 
replace  the  lost  tissue  (Fig.  252). 
After  this,  as,  in  fact,  after  all 
plastic  operations  in  this  region, 
the  normal  elastic  lip  is  substi- 
tuted by  a  flap  with  cicatricial 
edge.  As  time  passes,  this  edge 
contracts  and  is  drawn  tightly 
against  the  lower  jaw;  saliva 
runs  over  the  edge  in  spite  of 
every  effort  to  prevent  it.  The 
ingeniously  contrived  plastic  pro- 
cedure of  Langenbeck  (Fig. 
253)  possesses  an  advantage  in 
that  a  beard  can  be  grown  in 
such  a  manner  as  to  hide  the 
lines  of  the  union. 

Sandelin's  Method  of  Cheil- 
oplasty. —  S  a  n  d  e  1  i  n  com- 
bined the  method  of  sliding  a 
visor-like    flap    in    an     upward 

direction  to  cover  the  lip  (M  o  r  g  a  n)  with  Schulten's  method  of  trans- 
plantation of  a  flap  taken  from  the  upper  lip  and  including  both  mucous 
membrane  and  muscular  tissue.  The  method  is  as  follows:  The  edge  of  the 
defect  is  first  carefully  freshened.     A  transverse  curved  incision  is  then  made 


Fig.  254. — Sandelin's  Method  of  Cheiloplasty. 
1,  Line  of  incision  for  the  excision  of  the  growth; 
2,  line  of  incision  for  the  formation  of  the  visor  flap  of 
Morgan;  3,  the  visor  flap;  4,  Schulten's  line  of  incision 
for  the  formation  of  a  mucous  membrane  and  muscle  flap 
taken  from  the  upper  lip. 


484 


THE    SURGERY    OF   THE    HEAD 


below  the  chin  in  the  anterior  re<2;ion  of  the  neck  (Fig;.  254).  The  soft 
parts  are  now  dissected  from  the  chin  and  below  the  latter  to  an  extent 
sufficient  to  permit  sliding  upward  of  these  until  the  edge  of  the  defect 
can  be  placed  on  the  proper  level  without  tension,  where  it  is  secured  by 
a  short  steel  nail  driven  through  the  flap  and  into  the  bone.  A  curved 
incision  is  now  made  in  the  upper  lip  to  the  depth  of  from  three-eighths 
to  half  an  inch.     This  incision  splits  the  lip  so  as  to  form  an  anterior  and 

a  posterior  layer.  Care  must 
be  taken  in  making  this  incision 
and  splitting  the  lip  to  include 
both  muscle  and  mucous  mem- 
brane, and  to  preserve  the  coro- 
nary artery  in  the  posterior  layer 
of  the  flap  that  is  to  be  trans- 
planted. Accidental  injury  of  the 
coronary  artery  will  result  in 
sloughing  of  the  flap.  The  latter 
is  now  detached,  except  at  its 
extremities,  and  brought  down 
and  sutured  to  the  skin  edge  of 
the  defect  (Fig.  255).  In  sutur- 
ing the  flap  the  sutures  near  the 
angles  must  be  accurately  placed, 
in  order  to  preserve  proper  sym- 
metry of  the  mouth,  and  to  avoid 
subsequent  shrinkage. 

The  defect  left  in  the  upper 
lip  is  corrected  by  suturing  its 
edges  with  chromicized  catgut, 
and  the  gap  left  in  the  anterior 
portion  of  the  neck  is  closed  by  loosening  and  sliding  its  edges  and  suturing 
(Fig.  255).  The  amount  of  tissue  taken  from  the  upper  lip,  although  con- 
siderable, is  scarcely  missed.  Both  the  functional  and  the  cosmetic  results  are 
said  to  be  excellent. 


Fig.  255. — Sandelin's  Method  of  Chelioplasty. 
The  operation  completed  with  the  exception  of  the  clos- 
ure of  the  visor  flap  incision. 


CONGENITAL  MALFORMATIONS 

These  include  cleft  defects,  i.  e.,  labial  cleft  or  harelip,  vertical  cleft  of  the 
cheek,  and  horizontal  cheek  cleft  forming  a  macrostoma  or  enlargement  of  the 
mouth,  conjoined  with  which  there  is  usually  an  appendix  of  the  skin  in  front 
of  the  corresponding  ear.  Of  these,  harelip  is  the  most  common ;  this  is  con- 
fined almost  exclusively  to  the  upper  lip.  Cases  of  cleft  in  the  lower  lip  are 
very  rare,  though  such  have  been  reported.  Simultaneous  clefts  of  the  infe- 
rior maxilla  and  tongue,  in  addition  to  cleft  of  the  lower  lip,  have  been 
observed.     Fistulas  of  the  lower  lip  ma}^  occur  in  connection  with  harelip. 


HARELIP 


This  may  be  single,  double,  or  complicated  with  cleft  palate.  Almost 
without  exception,  it  is  laterally  placed  in  the  line  of  one  or  the  other  nares. 
In  the  rare  instances  reported,  in  which  the  median  cleft  was  present,  deformities 


THE    SOFT    PARTS    OF    THE    FACIAL    REGION 


485 


involving  absence  of  the  ethmoiil,  turl)inated  bones,  nasal  bones,  vomer,  and 
premaxiUary  bone  were  also  present.  Single  harelip  and  double  cleft  occur 
in  the  proportion  of  ten  to  one;    harelip  is  more  common  on  the  left  side. 

Three  degrees  of  harelip  are  recognized.  The  first  is  a  mere  notch  scared}'' 
passing  be^'ond  the  vermilion  border;  the  second  extends  nearly  or  quite  to 
the  nasal  orifice  and  there  terminates  (Fig. 
256).  while  the  third  passes  directl}^  into  the 
nasal  fossa  (Fig.  257).  The  first  two  may 
be  uncomplicated;  the  third  is  usually  asso- 
ciated with  cleft  palate  and  failure  of  union 
of  the  premaxiillary  bone.  This  degree  is 
often  present  in  single  harelip. 

In  double  harelip  the  fissures  may  be  of 
equal  length  (Fig.  258)  or  they  may  be  of 
the  second  degree  on  one  side  and  the  third 
degree  on  the  other.  The  intermaxillary 
bone  is  separated  from  the  alveolar  arches; 
it  may  carr}-  more  than  the  normal  number 
of  incisor  teeth.  At  least  two  fissures  exist 
in  the  alveloar  arch,  though  but  one  of  these 
is  continuous  with  the  cleft  in  the  hard 
palate,  unless  the  latter  is  also  double.     The 

prominence  of  the  intermaxillary  bone  (Fig.  258)  is  produced  by  its  freedom 
from  restraint :  it  is  crowded  forward  by  the  growth  of  the  vomer. 

Functional  Disturbances. — In  simple  harelip  of  the  first  and  second 
degrees  the  formation  of  labial  sounds  is  interfered  with.  In  case  of  the  third 
degree  disturbances  of  nutrition  mav  result  during  the  first  vear  of  hfe  from 


Fig.  256. — Sixgle  Hakelip. 


Fig.  257. — The  Thihd  Degree  of  H.vreijp. 
The  illustration  also  shows  a  method  of  controlling  bleeding  from  the  coronary  arteries  during  the  opera- 


inability  of  the  cliild  to  suckle  properlv.  Broncliitis  and  jDneumonia  may 
likewise  occur,  from  breathing  improperly  filtered  air.  In  cleft  palate  the 
voice  assumes  a  nasal  sound. 

These  congenital  clefts  are  the  result  of  failure  of  union  of  the  various  clefts 
between  the  branchial  arches  in  the  cephalic  extremity.     This  union  normally 


486  THE  SURGERY  OF  THE  HEAD 

occurs  at  about  the  ninth  or  tenth  week  of  fetal  life.  Incomplete  fusion  or 
failure  of  union  results  in  harelip,  cleft  palate,  and  other  deformities.  The 
number  of  instances  in  which  the  deformity  occurs  in  the  same  family  suggests 
a  hereditary  influence. 

The  Operative  Treatment  of  Harelip.— The  time  to  be  selected  for 
the  operation  is  of  some  importance.  While  many  considerations  impel  the 
surgeon  to  correct  the  deformity  as  early  as  possible,  notal)ly  those  arising 
from  the  desire  to  calm  the  anxieties  of  the  mother  and  those  referring  to  the 
dangers  which  threaten  the  child  itself,  the  condition  of  the  child  should 
nevertheless  be  borne  in  mind.  Swallowing  of  blood  by  a  newborn  infant  leads 
to  gastric  and  intestinal  catarrh.  Besides  this  danger,  children  operated  on 
early  do  not  bear  well  the  loss  of  blood.  Mgorous  children  artificially  fed  bear 
the  operation  well  and  may  be  operated  on  at  any  time;  in  the  case  of  weak 
and  sickly  children  it  is  l^etter  to  defer  the  operation  for  a  few  months,  as  long 
as  they  can  take  a  sufficient  amount  of  nourishment  on  which  to  base  a  hope  of 
improvement  in  the  general  condition.     Those  with  double  harehp  should  not 

be  operated  on  at  as  early  a  period  as  those 
with  single  harelip.  Cases  complicated  with 
cleft  palate  are  advantageously  operated  on 
during  the  first  year  of  life,  for  the  reason 
that,  with  closure  of  the  labial  cleft,  the 
palatal  cleft,  during  the  succeeding  few 
months,  grows  narrower. 

The  Anesthetic. — Chloroform  may  or 
may  not  l^e  administered.  While  anesthesia 
permits  a  more  accurate  operative  proced- 
ure, a  greater  quantity  of  blood  is  swal- 
lowed, and  inspired,  as  well.  If  the  opera- 
tion is  performed  without  an  anesthetic,  the 
child  is  wrapped  tightly  in  a  small  blanket 
and    held    bv   the  nurse,    the   head    being 

Fig.  258. — DorsLE  Harelip  axd  Promi-  ,   ,  "  •    ,        , 

NEXT  Intermaxillary  BoxE.  graspecl   by  an  aSSlStaut. 

General  Technic  of  Operations  for 
Harelip. — Special  pressure  clamps  for  the  prevention  of  hemorrhage  are  no 
longer  used.  The  fingers  of  an  assistant  grasp  the  lip  on  each  side  of  the 
cleft.  A  useful  device  is  to  pass  a  loop  of  thread  through  the  lip  at  a  sufficient 
distance  from  the  edge  to  be  out  of  the  way,  and  in  a  situation  to  control 
the  bleedmg  from  the  coronary  arteries  (Fig.  257).  These  loops  are  held  by 
an  assistant.  They  are  removed  when  the  sutures  corresponding  to  the  bleed- 
ing pomts  are  passed  and  tied. 

A  straight,  thin-bladed  bistoury  is  the  best  instrimient  for  the  formation  of 
the  flap.  Scissors  produce  more  contusion  of  the  parts.  As  the  flap  is  being 
formed  it  is  steadied  by  mouse-tooth  forceps  or  a  smaU  tenaculum.  A  pair  of 
blunt  scissors  cur\'ed  on  the  flat,  half  curved  needles,  and  a  needle  forceps  will 
also  be  required. 

The  flap  is  to  be  cut  after  the  manner  described  in  X  el  a  ton's, 
]\I  a  1  g  a  i  g  n  e  '  s ,  the  ]\I  i  r  a  u  1 1  -  L  a  n  g  e  n  b  e  c  k  ,  or  Simon's  method. 
In  order  to  assure  firm  union  of  the  sutured  edges  the  wound  surfaces  are 
made  as  broad  as  possible. 


THE    SOFT    PARTS    OF    THE    FACIAL    REGION  487 

Before  the  sutures  are  applied  the  flaps  must  be  relieved  of  all  tension  to 
prevent  the  sutures  from  cuttmg  out.  This  is  done  by  detaching  the  lips  from 
the  gums  by  the  curved  scissors,  care  bemg  taken  to  keep  the  latter  close  to  the 
o-unis.  The  tip  of  the  left  index-finger  lifts  the  structures  away  from  the  upper 
jaw  in  an  outward  and  upward  direction  and  at  the  same  time  ser^■es  as  a  guide 
for  the  scissors.  By  keeping  the  scissors  directed  toward  the  upper  jaw  the 
vessels  are  avoided.  The  relaxing  incisions  are  made  on  both  sides  and  the 
frenum  of  the  upper  lip  is  completely  separated.  The  superficial  bleedmg 
is  arrested  by  pressure. 

The  first  suture  is  applied  in  such  a  manner  as  to  arrest  the  hemorrhage. 
For  the  rest,  alternating  deep  or  tension  sutures  and  superficial  or  coaptation 
sutures  are  used.  Particular  attention  is  to  be  paid  to  the  accurate  adjustment 
of  the  edges  at  the  vermilion  border.  Silk  thread  is  to  be  employed.  In  tymg 
the  knots  care  should  be  taken  that  these  do  not  rest  on  the  line  of  union,  m 
which  situation  they  are  likely  to  interfere  with  the  accurate  adjustment  of  the 
edges.     Harelip  pins  are  no  longer  used. 


i 


Fig.  259. — Nelaton-'s  Operation-  for  Harelip. 
A,  The  incision;  B,   sutures  introduced. 

Methods  of  Operation  in  Single  Harelip.— Nelaton's  Operation.— TMs 

is  particLdarlv  applicable  to  fissm-es  of  the  first  degree.  The  lip  is  transfixed 
by  the  bistoury  above  the  angle.  The  knife  is  then  carried  m  a  direction 
parallel  tc  the  edge  of  the  cleft,  do^^iiward  and  toward  the  vermilion  border 
but  not  quite  to  Tt.  This  is  repeated  on  the  other  side,  formhig  a  A-shaped 
incision.  A  tenaculum  is  passed  through  the  apex  and  the  legs  of  the  A 
inverted,  leading  a  rhomboid  space  which  is  closed  by  suturing  (Fig.  259).  An 
over-correction,"as  sho^Aii  m  Fig.  259.  B.  should  be  obtained  in  order  to  allow 
for  subsequent  contraction. 

Malgaigne's  Operation. — The  incisions  are  made  as  m  Xela  ton's 
operation,  but  the  depressed  portion  is  cut  through  at  the  apex  in  order  to 
remove  the  redundant  portion  (Fig.  260). 

The  Mirault-Langenbeck  Operation.— This  is  applicable  to  harelip  of  the 
first  and  second  degree.  The  method  of  procedure  is  shown  m  Fig.  261. 
A  single  flap  is  taken  from  above  do^iiward.  but  is  left  attached  at  the 


488 


THE    SURGERY    OF    THE    HEAD 


prolabium.      The  margin  corresponding  to  the   median  edge  of  the  cleft  is 
freshened  at  an  obtuse  angle. 

Golding-Bird  Operation. — This  is  useful  in  harelip  of  the  second  degree. 
The  incisions  are  made  in  the  directions  sho^^^l  in  Fig.  262.  The  line  of 
union  resembles  somewhat  that  followuig  the  Mirault  operation. 


-  A 

/    ^ 


/.*"'  n|t. 


'^/p[>^ 


A  B 

Fig.  260. — Malgaigne's  Operation  for  Harelip. 
A,   The  incision ;  B,  sutures  introduced. 

Simon's  Operation  (Fig.  263). — In  this  operation  the  h  shaped  line, 
when  the  flap  and  freshened  edge  are  united,  forms  a  very  complete  correction 
of  the  deformity.  The  cicatricial  contraction  is  distributed  over  three 
separate  lines  and  the  minimum  amount  of  shrinkage  at  the  vermilion  border 
occurs.     This  operation  is  most  useful  in  harelip  of  the  third  degree. 


A  B 

Fig.  261. — Mirault-Langenbeck  Operation  for  Harelip. 
A,  The  incision;  B,   the  sutures  introduced. 


Choice  of  Operation. — In  newborn  children  and  during  early  infancy  and 
early  childhood,  other  things  being  ec{ual,  the  operation  which  involves  the 
least  loss  of  blood  should  be  chosen. 

In  harelip  of  the  third  degree  it  sometimes  becomes  necessary  to  equalize 
the  openings  in  the  nostrils.     When  necessary,  this  can  be  done  after  complete 


THE    SOFT   IWRTS    OF   THE    FACIAL   REGION 


489 


hoalinii-  and  contraction  of  tlio  jxirts  by  dotachiiip;  the  cartilaginous  septum  at 
the  floor  of  the  nasal  cavity  and  carrying  it  toward  the  wider  nostril,  a  place 
for  its  reception  having  been  previously  freshened.  It  is  here  sutured  and  the 
side  from  which  it  was  displaced  kept  plugged  A\-ith  antiseptic  gauze  until 
union  occurs. 

The  Operation  for  Double  Harelip.— Time  for  Operation.— Strong  and 
vigorous  children  may  be  operated  on  at  any 
time.  In  weak  children  the  operation  may  be 
delayed.  Even  in  these,  however,  failure  to 
maintain  the  nutrition  of  the  child  may  neces- 
sitate an  early  operation. 

Disposition  of  the  Intermaxillary  Bones. 
— In  cases  in  which  the  projection  is  but  slight 
or  entirely  absent  the  labial  clefts  may  be 
closed  at  once.  But  usually  the  intermaxillary 
bone  will  be  found  to  be  a  serious  obstacle  in 
the  way  of  restitution  of  the  parts. 

In  favorable  cases,  AA'ith  slightly  marked 
prominence,  the  removal  of  the  labial  cleft  ex- 
ercises a  favorable  influence  over  both  the  cleft 
and  the  prominent  bone;   the  latter  gradually 

recedes  to  its  normal  position  and  unites  with  the  alveolar  process.  A  con- 
siderable prominence,  however,  will  prevent  union  when  the  soft  parts  are 
brought  over  the  bone. 

Under  no  circumstances  must  the  intermaxillary  bone  be  removed.     The 
functional  and  cosmetic  effects  are  such  as  to  demand  its  retention.    In  order  to 


FiG.    262. — Golding-Bird's    Opera- 
tion FOR  Harelip. 


A  B 

Fig.  263. — Simon's  Operation. 
A,  The  incision ;  B,   the  sutures  introduced. 


effect  its  reduction,  fracture  and  the  crowding  backward  of  the  vomer  have 
been  employed ;  this  method  is  applicable  only  after  ossification  of  the  vomer  has 
taken  place.  The  method  of  excision  of  a  triangular  portion  of  the  vomer  close 
behind  the  intermaxillary  bone  (B  1  a  n  d  i  n)  is  to  be  preferred.  This  should 
be  done  through  an  incision  made  along  the  edge  of  the  vomer,  the  mucoperios- 


490 


THE    SURGERY    OF   THE    HEAD 


teal  covering  being  lifted  with  a  slender  elevator  and  a  A-shaped  gap  made 
by  sharp  scissors.  A  further  modification  of  B  1  a  n  d  i  n  '  s  operation  consists 
ill  niakmg  a  simple  vertical  section  of  the  bone.  This  is  done  subperiosteally 
also  (Fig.  264).  The  anterior  portion  is  now  forced  backward,  the  lateral 
surfaces  overlapping  each  other  and  becoming  united  (Rose). 

The  Operation. — The  skin  overlying  the  intermaxillary-  bone  is  pared  at 

its  margins  so  as  to  leave  a 
cjuadrangular  space  ^A^ith  three 
■wound  surfaces.  Then,  from 
the  outer  edge  of  each  cleft  a 
flap  is  formed,  the  lines  of  inci- 
sion being  similar  to  those  em- 
ployed in  M  a  1  g  a  i  g  n  e  '  s 
operation  (Fig.  260) ;  each  of 
these  flaps  is  left  attached  to 
the  lip  by  a  pedicle.  The  re- 
mamder  of  the  outer  edge  of 
each  cleft  is  freshened  by  re- 
moving the  margins  by  a  ver- 
tical cut.  The  flaps  taken  from 
the  outer  edge  of  the  clefts  are  now  apphed  to  the  horizontal  wound  surface 
of  the  central  portion ;  the  thm  extremity  of  each  flap  is  trimmed  so  as  to 
meet  in  the  middle  line  when  the  clefts  are  closed  (Fig.  265).  All  tension 
is  to  be  relieved  b}-  thoroughly  freeing  the  lip  and  cheek  from  the  bone. 

After=treatment  of  Harelip  Cases. — The  edges  of  the  wound  are  to 
be  thoroughly  dried  and  penciled  \^ith  a  mixture  of  collodion  and  subiodid  of 
bismuth.     Or  simple  occasional   cleansing  may  be  employed.     Xo  further 


Fig.  264. — The  Portion  In(  llded  ix  the  Solid  Lines 
IS  Removed  in  Blandin's  Operation.  The  Dotted 
Line  Represents  the  Site  of  the  Incision  in 
Rose's  Operation. 

1,  Vomer;  2,  premaxillary bone ;  3,  upper  lip;  4,  alveolar 
process  of  upper  jaw. 


A  B 

Fig.  265. — Operation  for  Double  Harelip. 

A,  The  incision ;  B,  sutures  introduced. 


dressing  is  required.  Strict  attention  on  the  part  of  the  nurse  is  necessary 
to  prevent  the  child  from  crying.  The  cavity  of  the  mouth  should  be  cleansed 
occasionally  with  a  weak  boric  acid  solution.  Bits  of  absorbent  cotton  tied 
on  a  stick  and  dipped  in  the  solution  are  best  for  this  purpose.  If  the  bowels 
do  not  move  after  the  first  da}',  a  suitable  purge  should  be  given.  The  first 
defecations  will  be  dark  colored  as  a  result  of  the  blood  swallowed. 


THE    SOFT   PARTS    OF   THE    FACIAL   REGION 


491 


Removal  of  the  Sutures. — The  sutures  should  be  removed  at  the  end  of 
a  week.  Union  is  usuahy  found  to  be  complete.  If  the  union  is  only  partial, 
the  vermilion  border,  at  least,  is  generally  found  to  be  united;  the  remainder 
of  the  cleft  will  unite  by  granulation,  which  may  be  assisted  by  strapping  with 
adhesive  plaster.  In  case  of  complete  failure  a  second  operation  should  be 
performed  after  from  four  to  six  weeks. 

Hemorrhage  is  the  chief  danger  from  the  operative  procedure  itself.  Bron- 
chopneumonia constitutes  the  chief  after-danger. 

Congenital  Fissure  of  the  Cheek. — This  is  observed  (1)  as  a  vertical 
cleft  :  (2)  as  a  horizontal  cleft ;  (3)  as  an  angular  fissure. 

Vertical  fissure  arises  either  from  defective  union  or  from  total  failure  of 
one  lateral  plate  to  join  the  midfrontal  process.  In  the  most  aggravated  cases 
the  fissure  reaches  to  the  lower  eyelid,  constituting  one  of  the  forms  of  colo- 
boma  palpebrae,  the  conjunctiva  being  connected  with  the  mucous  membrane 


Fig.  266. — Fissure   of   the   Cheek,    Fissure  of   the    Upper   Eyelid,  axd  Auricular  Appexdages. 


of  the  edges  of  the  cheek  cleft  and  through  the  latter  with  that  of  the  enlarged 
oral  orifice.  The  cleft  may  continue  through  the  upper  eyelid  to  the  forehead 
or  it  may  be  connected  with  the  nasal  cavity. 

Horizontal  fissure  of  the  cheek  is  the  result  of  a  failure  on  the  part  of 
the  edges  of  the  highest  branchial  arch  to  unite.  An  enormxous  enlargement 
of  the  mouth  (macrostoma)  is  formed;  the  mouth  may  reach  from  ear  to  ear. 
Skm  appendices  in  front  of  the  auricle  are  sometimes  seen  in  connection  with 
tliis  deformity  (Fig.  266). 

Angular  fissure  is  sometimes  observed.  Ferguson  records  an 
instance  in  which  the  cleft  extended  from  the  left  angle  of  the  mouth  to  the  base 
of  the  lower  jaw.  It  occurs  occasionally  on  both  sides  and  simultaneously 
with  other  cleft  deformities,  as  well  as  with  congenital  hypertrophy  of  the 
tongue  (macroglossia). 

Exceptionally  the  edges  of  the  cleft  appear  in  fissure  of  the  cheek  as  scar 


492 


THE    SURGERY    OF   THE    HEAD 


tissue.  In  the  majority  of  instances  of  the  deformity  the  angle  of  the  cleft  is 
attached  to  the  gums  by  a  connecting  bridge  or  frenum;  more  rarely  to  the 
hard  i)alate. 

Treatment. — The  edges  of  the  fissure  are  to  be  freshened  and  the  opposing 
surfaces  brought  together  and  united  by  sutures.  In  the  case  of  horizontal 
cheek  clefts  with  macroglossia  the  verinilion  border  of  the  cleft  is  to  be  dissected 
loose  throughout  its  entire  length,  the  incision  commencing  at  a  point  on  the 
upper  lip  where  the  angle  of  the  mouth  should  be,  and  terminating  on  the  lower 
lip  about  one-eighth  of  an  inch  nearer  the  median  line  than  the  above  point 
(Fig.  267,  A).  The  strip  is  then  released  by  cutting  directly  upward  through 
the  lower  lip,  when  it  is  shortened  sufficiently  to  allow  accurate  adjustment  in 
the  formation  of  a  new  angle  of  the  mouth.  The  strip  is  now'  secured  in  posi- 
tion with  fine  silk  sutures  and  the  gap  in  the  cheek  sutured  (Fig.  267,  B). 

Congenital  Anomalies  of  the  Eyelids. — Complete  absence  of  the  eyelid 
is  of  rare  occurrence.  Imperfect  development  of  the  lid  resulting  in  a  fissure 
(coloboma)  is  occasionally  observed.      In  some  instances  the  entire  thickness  of 


A  B 

Fig.  267. — The  Operation  for  Cleft  Chicek  and  Macrostoma. 
The  vermilion  strip  is  sutured  in  position  and  the  gap  in  the  cheek  closed. 


the  lid  is  wanting  (Fig.  266),  while  in  others  a  membranous  intermediate  portion 
occupies  a  part  or  all  of  the  gap  in  the  lid.  Both  the  upper  and  the  loA\-er  hd 
on  one  or  both  sides  may  be  affected,  or  both  upper  lids  or  the  upper  lid  of  one 
eye  may  be  involved.  Coloboma  of  the  eyelids  may  exist  alone  or  it  may  occur 
in  conjunction  with  other  malformations  of  the  eye,  harelip,  and  clefts  of  the 
cheek,  nose,  hard  and  soft  palate,  and  pharynx. 

The  treatment  consists  in  paring  the  edges  of  the  fissure  and  unithig  the 
freshened  surface  by  sutures. 

Congenital  Fistulas.— These  are  observed  in  the  face,  on  the  bridge  of 
the  nose,  in  the  median  line,  at  the  lower  extremity  of  the  nasal  septum,  on  the 
lower  lip,  in  front  of  the  ear,  and  behind  the  lobe  of  the  ear.  They  can  usually 
be  traced  ■v^ith  a  fine  probe  for  a  distance  of  from  half  to  three-fourths  of  an 
inch  beneath  the  skin,  the  fistula  apparently  terminating  in  a  cavity.  They 
may  lead  from  the  nose  to  the  base  of  the  skull  (C  r  u  v  i  e  1  h  i  e  r,  K  1  e  b  s) ; 
from  the  termination  of  the  nasal  septum  to  the  nasal  cavity  (R  u  y  s  c  h) ;  or 
from  just  behind  the  ear  to  the  cavity  of  the  mouth  (Rose).     The  entire 


THE    SOFT   PARTS    OF    THE    FACIAL   REGION  493 

fistulous  track  may  be  lined  Avith  epidermis  (Beely).  Their  place  of  exit 
on  the  skin  is  occasionally  the  seat  of  an  intractable  eczema. 

"When  the  canal  beneath  the  skin  can  be  accurately  followed,  extirpation  is 
indicated.  This  may  be  facilitated  by  leaving  a  probe  in  situ  while  the  dissec- 
tion is  being  made. 

Fistulas  of  the  Lower  Lip. — These  are  usually  accompanied  by  a  strongly 
prominent  lower  lip,  on  the  vermilion  border  of  which  appear  two  shallow 
dimples.  At  the  base  of  each  of  these  near  the  median  line  the  opening  of  a 
fistula  is  found,  the  size  of  the  head  of  a  pm,  from  which  more  or  less  watery 
salivalike  fluid  exudes.  The  canals  diverge,  as  a  rule,  and  can  be  followed  by 
a  probe  a  distance  of  from  three-fourths  of  an  inch  to  one  and  one-fourth  inches, 
ending  in  a  blind  passage.  At  the  lower  portion  of  their  course  and  in  the 
thick  part  of  the  hp  they  approach  the  mucous  membrane  of  the  mouth.  The 
fistulous  opening  is  surrounded  by  muscular  tissue,  which  becomes  narrow,  or 
gapes,  A^th  movements  of  the  parts.  A  snout-shaped  lip  is  sometimes  formed 
by  a  doA^mward  and  outward  lengthening  of  the  lip. 

The'  condition  may  be  associated  with  other  facial  deformities,  notably 
harelip,  as  well  as  malformations  m  other  and  remote  parts.  Heredity  hke- 
wise  enters  into  the  causation.  Defective  embryonal  development  of  the 
furrows  on  either  side  of  the  intermaxillary  or  thin  portion  of  the  mandibular 
process,  together  A^ith  o^'e^growth  of  the  latter  in  cases  of  snout-shaped  projec- 
tion of  the  lip,  originates  the  deformity. 

Should  the  prominent  lip  or  persistent  secretion  demand  it,  a  wedge-shaped 
portion  including  the  fistulous  canal  may  be  excised. 

Auricular  Appendages. — Congenital  tumors  m  front  of  the  ear,  varying 
in  size  from  a  lentil  to  a  pea,  are  sometimes  obser\'ed  projectmg  above  the 
surrounding  level,  the  so-called  auricular  appendages  (Fig.  2661.  These  appear 
in  some  cases  to  be  simply  reduplications  of  the  skin,  while  in  others  a  decidedly 
cartilaginous  structure  is  found  in  the  interior.  Occasionally  they  are  attached 
by  a  narrow  pedicle.  They  occur  on  one  side,  as  well  as  symmetrically  on  both 
sides.  Sometimes  there  is  a  simultaneous  malformation  of  the  external  ear, 
in  which  case  the  appendages  take  on  a  larger  form.  They  may  be  simply 
snipped  off  Anth  the  scissors.  A  small  vessel  may  reciuire  the  application  of  a 
suture. 

Stomatoplastic  Operations. — These  operations  differ  from  cheiloplasty 
in  that  they  aim  at  correcting  congenital  mouth  formation  rather  than  replace- 
ment of  parts  lost  by  injur\'  or  disease.  The  conditions  most  frequently 
requiring  their  performance  are  (1)  macrostoma;  (2)  microstonia;  (3) 
ectropion  of  the  lips. 

Macrostoma. — In  case  of  congenitally  large  mouth  the  plastic  operation 
for  forming  a  new  angle  of  the  mouth  described  in  connection  with  horizontal 
fissure  of  the  cheek  (vide  supro)  is  to  be  preferred  to  the  usual  procedure  of 
freshening  the  edges  of  the  angle  of  the  mouth  and  uniting  the  same  by  sutur- 
ing.    There  is  usually  no  tension  on  the  parts  and  union  is  rapid  and  complete. 

Microstoma  is  seldom  congenital.  Its  most  common  cause  is  cicatricial 
contraction  of  the  mouth  foUoxAing  disease  or  mjur}'.  It  is  corrected  by 
making  an  incision  for  the  necessars^  distance  beyond  the  angle  of  the  mouth 
and  lining  this  ■v^ith  mucous  membrane  from  the  cheek,  which  is  loosened  for 
this  purpose.     In  order  to  prevent  the  incision  from  granulatmg  together  from 


494  THE  SURGERY  OF  THE  HEAD 

the  angle  in^vard  toward  the  median  Hne,  the  incision  is  prolonged  as  a  Y 
placed  horizontally  at  the  angle  and  the  mucous  membrane  of  the  cheek 
loosened  more  extensivel}^  at  this  point.  The  triangular-shaped  flap  of 
mucous  membrane  is  sewed  to  the  new  angle.  Or  the  older  method 
of  R  u  d  t  o  r  f  f  e  r  may  be  tried.  This  consists  in  perforating  the  cheek 
at  the  point  where  the  neAV  angle  is  to  be  formed,  and  passing  through  the 
opening  a  metallic  wire.  When  cicatrization  of  the  opening  is  complete,  the 
usual  incision  is  made  from  this  point  to  the  already  existing  oral  opening 
and  covered  with  mucous  membrane  after  Dieffenbach's  method. 
The  difficulty  in  obtaining  cicatrization  of  the  opening  through  ^^'hich'  the 
wires  are  passed  constitutes  the  chief  objection  to  this  method.  The  patient 
wears  an  oval  double-faced  ring,  made  of  hard  rubber,  for  an  hour  or  more 
each  day  in  order  to  prevent  recontraction. 

Ectropion  of  the  lips,  or  eversion  from  cicatricial  contraction  of  the 
mucous  membrane  lining  the  lip,  in  its  complex  forms  is  to  be  corrected  by 
V-shaped  excision  of  the  cicatrix  and  Y-shaped  union  of  the  gap  (vide  infra) . 
In  other  and  more  severe  cases  cheiloplastic  procedures  are  indicated.  Separat- 
hig  the  labial  edges  from  the  cicatricial  tissue,  raising  them  to  the  proper 
level  and  filling  the  gap  by  a  flap  with  a  pedicle,  ^^^lll  prove  successful  in  a 
certain  number  of  cases. 

Meloplastic  Operations. — Operations  designed  to  correct  defects  in  the 
soft  parts  of  the  cheeks  are  less  frequently  required  than  plastic  operations 
in  other  portions  of  the  face.  The  skin  of  the  temporal  region  and  of  the 
forehead  is  most  frequently  utilized  for  this  purpose,  where  the  loss  of  sub- 
stance is  complete. 

Schimmelbusch's  operation  is  to  be  employed  after  removal  of  the  entire 
cheek.  The  first  flap  is  reflected  upward  from  the  neck,  and,  ^vhen  in  position, 
its  skin  surface  replaces  the  buccal  mucous  membrane.  The  second  flap  is 
taken  from  the  scalp,  and,  when  turned  downward,  its  rav/  surface  is  presented 
to  the  raw  surface  of  the  first  flap,  its  outer  hairy  surface  replacing  the  beard. 
The  pedicles  are  divided  in  four  weeks. 

In  partial  defects  flaps  with  small  pedicles  are  successfidly  employed  on 
account  of  the  rich  blood-supply.  When  in  the  extirpation  of  a  growth  the 
mucous  membrane  cannot  be  spared,  this  structure  is  not  easily  replaced; 
the  buccal  surfac^e  of  a  skin  flap  is  likely  to  undergo  cicatricial  contraction. 

In  cicatricial  lockjaw  folio-wing  noma  the  cicatrix  must  be  divided,  and, 
in  order  to  prevent  recontraction,  the  defect  filled  with  double  skin  flaps, 
one  integumentary  surface  facing  the  buccal  cavity  and  the  other  presenting 
externally  (Gussenbauer). 

Blepharoplastic  Operations. — Cicatricial  deformities  of  the  eyelids  con- 
stitute the  most  frequent  indication  for  these  operations;  they  are  some- 
times resorted  to  after  the  extirpation  of  morbid  gro^vths.  Ectropion,  or  a 
turning  outward  of  the  lid,  is  the  most  common  of  these;  the  lower  lid  is  most 
frec^uently  affected.  A  condition  of  entropion  attends  cicatricial  contraction 
of  the  conjunctival  surface  of  the  lids. 

The  first  step  in  the  correction  of  ectropion  is  the  separation  of  the  everted 
conjunctiva  from  the  underlying  cicatricial  tissue.  The  edge  of  the  eyelid 
is  then  restored  to  its  normal  position.  In  partial  ectropion  a  simple  V-shaped 
incision  made  by  dissecting  up  the  triangular-shaped  flap,  sliding  it  in  an 


SOFT   PARTS    OF    THE    NOSE    AND    NASAL    CAVITIES 


495 


upward  direction,  and  suturing  this  so  as  to  form  a  Y-shaped  line  of  union,  after 
restoration  of  the  hd  to  the  proper  level,  suffices  (Fig.  268).     Complete  ectro- 


1 

^^^^^^Hnrv 

~^ 

Y 

> 

Fig.  268. — Operation  for  Simple  Ectropion. 
A,  The  incision;  B,  the  Y-shaped  Une  of  union. 

pion  is  best  remedied  by  making  the  incision  along  the  tarsal  margm,  dis- 
secting the  conjunctiva  loose,  restoring  the  edge  of  the  lid  to  the  proper 
level,  and  suppiymg  the  then  existing  defect  by  a  flap  from  the  temporal 
regions  (Fig.  269).  The  trans- 
planted portion  must  be  at  least 
t\\ice  as  large  as  the  defect  to 
be  corrected.  The  use  of  R  e  - 
V  e  r  d  i  n  transplanted  flaps  or 
the  method  of  Thiersch  like- 
^^ise  gives  good  results.  All 
methods  are  followed  by  slight 
relapses  in  a  certain  proportion 
of  cases.  These  are  to  be  cor- 
rected by  subsequent,  though  less 
formidable,  operations.  In  ectro- 
pion of  the  upper  lid  the  same 
procedures  suffice,  the  lines  of  the 
incision  being  reversed.  Fig.  269.-Fricke's  method  of  blepharoplastt. 

Ectropion    of    both    lids    is 
sometimes  treated  bv  tarsorrhaphy,  the  lids  bemg  sewed  together  over  the 
globe  after  correction  of  the  defects,  until  complete  healmg  has  taken  place. 


THE  SOFT  PARTS  OF  THE  NOSE  AND  NASAL  CAVITIES 

The  onlv  injuries  of  the  soft  parts  of  the  nose  requiring  special  notice  are 

those  v.-hich  involve  the  alae.     Portions  of  the  latter,  though  entirely  separated, 

should  be  at  once  replaced  after  careful  cleansing;  they  occasionally  unite,  even 

some  hours  after  the  injury.     If  they  fail  to  do  so.  certain  plastic  operations  are 

indicated. 

Fractures  of  the  Nasal  Bones.— These  are  always  the  result  of  direct 


496 


THE    SURGERY    OF    THE    HEAD 


Fig.  270. — Asch's  Open  Scissors. 


The  best  expedient,  if  spon- 


violence.  The  fragments  are  displaced  in  the  direction  of  the  nasal  cavity. 
These,  if  permitted  to  remain,  lead  to  a  saddle-shaped  deformity  of  the  organ. 
In  addition  to  the  cosmetic  effects,  certain  functional  disturbances,  such  as 
embarrassment  of  respiration,  loss  of  sense  of  smell,  etc.,  follow.  The  indica- 
tions, therefore,  are  to  replace  the  fragments  as  soon  as  possible.     This  is  best 

accomplished  by  a  pair  of  dress- 
ing forceps  introduced  in  the  nos- 
tril, first  on  one  side  and  then  on 
the  other,  the  fragments  on  the 
outside  being  supported  with  the 
thumb  and  finger  of  the  other 
hand.  By  pressure  made  upward 
the  displaced  fragments  are 
forced  into  position.  The  sep- 
tum, if  displaced,  is  to  be  straightened  forcibly  by  grasping  it  with  the  dress- 
ing forceps  and  making  pressure  in  the  proper  direction.  Retention  of  the 
fragments,  after  reduction,  sometimes  requires  nothing  more  than  simple 
packing  of  the  nostril  ^^dth  antiseptic  gauze.  This  sometimes  produces  so 
much  irritation  as  to  lead  to  its  abandonment, 
taneous  retention  does  not  occur, 
is  to  pass  a  needle,  grasped  in  a 
stout  forceps,  by  drilling  move- 
ments through  the  fragments 
from  side  to  side.  A  narrow 
piece  of  adhesive  plaster  is  now 
passed  over  the  bridge  of  the 
nose  and  made  to  include  the 
two    ends   of    the    needle.     The 

latter  may  be  ■\\ithdra'v\Ti  at  the  end  of  a  week  or  ten  days  (Mason). 
Sometimes  as  a  result  of  traumatism,  but  more  frequently  from  abnor- 
malities of  growth  (Harrison  Allen),  deviations  of  the  septum  are 
observed.  The  deviation  may  affect  the  cartilaginous  septum  alone,  or  the 
vomer  may  likewise  be  involved.  No  difficulty  should  be  experienced  in 
diagnosing  these  deformities;  only  the  most  superfi- 
cial observation  could  possibl}'  mistake  them  for  new 
growths. 

The  treatment  consists  in  thoroughly  dividing  all 
adhesions  to  the  turbinates,  and  making  two  inter- 
secting incisions  at  the  point  of  greatest  convexity  of 
the  deformed  septum  by  means  of  the  open  scissors 
(A  s  c  h.  Fig.  270).  The  finger  is  then  introduced 
into  the  obstructed  side  and  the  four  segments  of 
cartilage  made  by  the  intersecting  incisions  broken  at 
their  bases  by  forcing  them  into  the  concavity.  The 
septum  is  then  straightened  by  powerful  compression  forceps  (Fig.  271)  and  a 
snugly  fitting  vulcanized  tube  splint  (Fig.  272).  In  case  the  vomer  is  prim- 
arily at  fault,  this  may  be  corrected  by  dissecting  the  upper  lip  from  the 
alveolar  side  and  detaching  the  anterior  portion  of  the  vomer  with  the 
attached  cartilaginous  septum  from  the  superior  maxillary  bone  by  means 


Fig. 


1. — Compression"  Fohcki-s  for  Stkaightexing 
THE  Septum. 


Fig.  272. — Asch's  Vulcan- 
ized Tube  Splint. 


SOFT  PARTS    OF   THE    NOSE   AND    NASAL   CAVITIES  497 

of  the  bone-cutting  forceps.  The  entire  septum  is  then  crowded  over  to  its 
normal  position  and  there  maintained  by  the  suitable  packing  of  the  formerly 
narrowed  nares  (L  o  s  s  e  n). 

Epistaxis. — This  may  occur  from  external  injuries  or  from  injuries  of 
a  vessel  frequently  found  at  the  anterior  portion  of  the  cartilaginous  septum, 
which  is  easily  invaded  by  forcible  attempts  to  remove  crusts  from  the  nasal 
cavity.  Acute  and  chronic  inflammatory  conditions,  ulcerative  conditions 
of  the  mucous  membrane,  tumors,  etc.,  and  finally  defective  cardiac  action, 
as  well  as  hemophilia  and  the  beginning  of  typhoid  fever,  give  rise  to  alarm- 
ing hemorrhages. 

The  treatment  consists  in  the  application  of  cold,  either  externally  by 
means  of  ice  over  the  bridge  of  the  nose,  or  the  use  of  ice-water  snuffed  up 
the  nose  or  injected  by  means  of  a  syringe.  In  mild  cases  deep  inspirations 
will  sometimes  suffice  to  arrest  the  bleeding.  By  this  means  the  mucous 
membrane  is  emptied  of  its  blood  by  aspiration,  and  at  the  same  time  the 
blood  which  has  escaped  from  the  vessel  is  forced  against  the  open  point  and 
coagulation  favored.  This  failing,  plugging  of  the  anterior  nares  with  non- 
absorbent  cotton  is  the  next  step  to  be  taken.  These  plugs  should  be  forced 
as  deeply  as  possible  into  the  nasal  cavity  b}'  a  screwing  movement.  Hemor- 
rhage may  now  persist  from  the  posterior  nares,  in  w^hich  case  it  ■wall  be  neces- 
sary to  resort  to  the  plugging  of  both  posterior  and  anterior  nares.  This  may 
be  accomplished,  in  case  of  emergency,  by  the  use  of  a  soft-rubber  catheter, 
which  is  passed  through  the  anterior  nares,  grasped  with  a  pair  of  forceps  as  it 
emerges  from  behind  the  u\aila,  after  which  it  is  dra^m  over  the  back  of  the 
tongue  and  thence  out  of  the  mouth.  Here  a  doubled  strand  of  strong 
thread  about  a  foot  long  is  tied  to  it.  In  the  middle  of  this,  a  firm  wad  of 
common  cotton  (nonabsorbent)  is  tied.  The  catheter  is  now  withdra\^TL  by 
dra^^ing  on  the  end  projecting  from  the  anterior  nares,  the  forefinger  of  the  left 
hand  at  the  same  time  guiding  the  cotton  plug  attached  to  the  string  over 
the  base  of  the  tongue  and  up  behind  the  uvula  until  it  is  safely  lodged 
crosswise,  at  the  posterior  nares.  The  end  projecting  from  the  mouth  is 
permitted  to  remain  for  the  purpose  of  withdrawing  the  plug  when  necessary. 
The  double  strand  which  projects  from  the  anterior  nares  is  separated,  a  tightly 
rolled  wad  of  cotton  placed  outside  the  nose  and  between  the  strands,  and 
the  latter  tied  over  this,  to  serve  as  a  plug  to  the  anterior  nares.  If  a 
Bellocq's  cannula  is  at  hand,  this  may  be  advantageouslv  emploved 
(Fig.  273). 

Rubber  balloons,  on  the  principle  of  Barnes's  uterine  dilators,  have 
been  suggested,  these  being  filled  ^^ith  air  or  ice- water,  after  introduction. 
Passing  a  fold  of  gauze  or  linen,  covered  with  vaselin,  well  into  the  nasal 
cavity  and  packing  this  with  cotton,  answers  as  well,  and  can  be  improvised 
in  cases  where  this  would  suffice. 

Rhinoscopy. — Inspection  of  the  nasal  cavities  is  required  for  the  exact 
diagnosis  of  foreign  bodies,  acute  and  chronic  inflammatory  conditions,  and 
tumors.  In  order  to  accomplish  this  the  parts  must  be  dilated  and  illumi- 
nated. Direct  inspection  through  the  nostrils  in  front  is  called  anterior  rhinos- 
copy ;  where  a  mirror  is  placed  in  the  fauces  and  rays  of  light  are  reflected 
on  this,  illuminating  the  parts  and  at  the  same  time  reflecting  their  image 
in  the  mirror,  the  manipulation  is  known  as  posterior  rhinoscopy. 
33 


498 


THE    SURGERY   OF   THE    HEAD 


Anterior  rhinoscopy  is  made  by  dilatiiijij  tlie  flexible  portions  of  the  nos- 
trils by  means  of  a  suitable  speculum,  and  illuminating  the  cavity  by  means 
of  hght  reflected  from  the  surface  of  a  concave  mirror.  A  convenient  form 
of  self-retaining  speculum  for  this  purpose  is  shown  in   Vig.  274.     Forcible 


Fig.  273. — Bellocq's  Cannula  with  the  Spring  Carrier  Projected. 

elevation  of  the  tip  of  the  nose,  in  conjunction  with  the  use  of  the  speculum, 
permits  accurate  inspection.  Turning  the  patient's  head  from  side  to  side 
will  facilitate  the  examination  of  the  different  parts. 

Posterior  Rhinoscopy. — This  is  more  difficult  than  the  anterior  method. 


Fig.  274. — Self-retaining 
Nasal  Speculum. 


Fig.  275. — Nasal  Ele(  tuic  Light  Specu- 
lum. 


A  mirror  is  placed  in  the  pharynx,  from  w^hich  light  is  reflected  into  the  pos- 
terior nares;  the  palate  must  remain  completely  relaxed  and  the  tongue 
depressed.  The  palate  can  sometimes  be  controlled  b}'  the  patient  if  he  is 
directed  to  say  "Eh"  with  a  strong  nasal  sound.     If  after  a  few  patient  Irials 


SOFT   PARTS    OF    THE    XOSE    AND    NASAL    CAVITIES 


499 


the  uvula  is  still  found  to  be  irritable  and  disposed  to  drag  up  forcibly  against 
the  surface  of  the  mirror,  the  parts  may  be  anesthetized  ^^■ith  an  application 
of  a  10  or  20  per  cent  solution  of  cocain.  Before  resorting  to  this,  which 
is  very  disagreeable  to  the  patient,  an  attempt  may  be  made  to  steady  the 


Fig.  276. — French's  Pal.\.te  Hook. 


soft  palate  by  means  of  a  palate  hook.  The  most  efficient  of  these  hooks  is 
that  devised  by  Dr.  T,  R.  French  (Fig.  276) .  The  tongue  is  to  be 
kept  out  of  the  way  by  means  of  a  tongue  depressor.  In  depressing  the  tongue 
care  should  be  taken  to  drag  it  forward  at  the  same  time,  rather  than 
permit  it  to  be  forced 
back  against  the  fauces; 
the  latter  produces  gag- 
ging. 

In  order  to  be  able 
properly  to  diagnose  mor- 
bid conditions  about  the 
posterior  nares.  the  sur- 
geon should  familiarize 
himself  with  the  appear- 
ances of  the  parts  in 
health  (Figs.  277.278). 

Foreign  Bodies  in 
the  Nose.  —  A  foreign 
body  in  the  nose  is  of 
rather  common  occur- 
rence among  children,  as 
the  result  of  either  mis- 
cliief  or  accident.  In  the 
act  of  vomiting,  portions 
of  the  contents  of  the 
stomach  find  their  way 
into  the  nose  through  the 
posterior  nares.  Soft  arti- 
cles of  food  in  this  local- 
ity are  easily  expelled; 
the  stones  of  fruit  which 
have  been  swallowed,  or 
other  ingested  articles. 
however,  ma}'  give  rise 
to  considerable  irritation. 

Children  often  place  beans,  peas,  and  buttons  in  the  nose,  in  play,  though 
anxious  mothers  sometimes  imagine  that  their  children  ha-\'e  placed  a  button 
or  some  other  foreign  bodv  in  the  nose  when  this  is  not  reallv  the  case. 


Fig. 


-Posterior  Rhixoscopic  Examination-. 


500 


THE    SURGERY   OF   THE    HEAD 


The  presence  of  a  foreign  body  in  the  nose  at  once  produces  a  more  or  less 
profuse  seromucous  discharge ;  this  soon  becomes  mucopurulent  or  even  bloody 
if  ulceration  results. 

The  diagnosis  should  be  made  between  foreign  bod}-  producing  irritation  and 
ulceration  and  syphilitic  nasal  disease.  Carcinoma  and  sarcoma  may  give  rise 
to  the  same  symptoms.  The  escape  of  flocculent  or  cheesy  masses  with  the 
discharge  is  characteristic  of  foreign  body  (B  o  s  w  o  r  t  h).  When  ulceration 
is  present,  it  is  neither  progressive  nor  extensive;  necrosis  is  very  rare.  If 
the  foreign  body  is  well  forward  it  may  produce  deformity.     Instrumental 

examination  should  be  preceded  by  cocain 
anesthesia.  A  thorough  preliminary  wash- 
ing of  the  nasal  fossae  with  a  mild  alka- 
line solution  will  enhance  the  anesthetic 
effects  of  the  cocain.  Chloroform  may  be 
administered  to  young  children.  The 
probe  will  usually  detect  readily  the  pres- 
ence of  the  foreign  body.  Previous  un- 
successful attempts  to  remove  the  foreign 
body  may  have  denuded  the  turbinated 
bones  of  their  coverings.  The  probe  com- 
ing in  contact  with  bare  bone  ma}'  mis- 
lead the  surgeon.  Inspection  by  anterior 
rhinoscopy  may  assist. 

The  treatment  is  very  simple.  An 
ordinary  wire  curet  of  the  proper  size 
will  serv'e  to  dislodge  almost  any  foreign 
body  that  can  be  crowded  into  the  nose 
(Fig.  279).  This  may  sometimes  be  improvised  from  an  ordinary'  hairpin. 
If  clirectly  \\ithin  reach,  the  foreign  body  may  be  grasped  with  a  pair  of  forceps. 
If  lodged  far  back,  a  finger  passed  from  the  pharynx  into  the  posterior  nares  ^^ill 
assist  in  steadying  the  object  while  it  is  being  extracted  with  the  loop  of  the  curet. 
Inflammation  and  Tumors  of  the  Covering  of  the  Nose.— The  presence 
of  short  connective-tissue  fibers  between  the  skin  and  the  periosteum  and  peri- 
chondrium of  the  nose  is  unfavorable  to  the  development  of  phlegmonous  inflam- 
mation of  the  nasal  covering.     Erysipelas,  however,  develops  readily;    the 


Fig.  278. — Rhixoscopic  Im.4ge. 

The  illustration  is  shown  larger  than  normal 

in  order  to  bring  out  the  parts  in  detail. 


Fig.  279. — Small  Wire  Curet. 


broad  follicles  with  open  mouths  favor  acne  and  pustulous  affections  and  the 
infection  of  erysipelas  enters  and  extends  rapidly. 

Acne  rosacea  is  a  hyperplastic  process,  consisting  of  a  proHferation  of  the 
skin  tissue,  with  development  of  blood-vessels.  It  is  generally  a  bright  red 
or  bluish  color.  Uneciual  development  leads  to  a  warthke  or  uneven  appear- 
ance in  some  cases.  It  is  popularly  associated  with  the  abuse  of  alcoholic 
stimulants,  though  it  does  not  necessarily  arise  from  this  cause.  It  occurs 
more  particularly  in  middle  age  and  late  in  life.  Removing  the  skin  from 
the  entire  nose  and  replacing  this  by  Thiersch's  skin  transplantation. 


SOFT   PARTS    OF   THE    NOSE    AND    NASAL    CAVITIES 


501 


or  permitting  the  space  to  fill  up  with  granulation  tissue,  though  a  severe 
remedy,  is  the  only  resource  in  the  most  severe  cases.  Fusiform  excision 
frequently  repeated,  and  the  suturing  of  the  edges  of  the  gaps,  may  be  resorted 
to  in  less  severe  cases.  Solutions  of  the  aqueous  extract  of  ergot  and  carbolic 
acid  (aqueous  extract  of  ergot,  1 ;  distilled  water,  10;  carbolic  acid,  10)  injected 
in  small  quantities  into  the  skin  and  beneath  its  surface  have  been  used  with 
some  success  (R  i  e  s  m  y  e  r). 

Lupus. — This  commences  in  the  hyperplastic  granulating  form  and  after- 
ward passes  more  deeply,  finally  involving  the  cartilages,  and  ulcerating. 
It  may  spread  over  the  entire  surface  of  the  organ,  reach  the  nasal  bones,  and 
extend  laterally  to  the  nasal  processes  of  the  superior  maxillary  bones.  The 
septum  suffers  in  the  general  destruction  and  the  tip  of  the  nose  becomes 
depressed  in  consequence.  Excision  and  skin  transplantation  after 
T  h  i  e  r  s  c  h  is  the  best  remedy 
(see  page  331). 

Rhinoscleroma  is  a  dis- 
ease characterized  by  an  ex- 
tremely chronic  inflammation 
of  the  coverings  of  the  nose. 
The  nasal  mucous  membrane,  as 
well  as  that  of  the  phar\mx  and 
larjmx,  may  be  involved.  It 
sometimes  produces  great  de- 
formity. It  is  marked  by  the 
occurrence  of  hard  grayish-red 
nodules  covered  with  normal 
epidermis,  the  tissue  of  which 
is  infiltrated  with  round  cells. 
These  are  the  sites  of  numer- 
ous large  lymphatic  vessels. 
Ulceration  may  occur  in  the 
large  nodules.  A  specific  bacil- 
lus has  been  shown  to  exist  in 
the  disease  (Finch)  and  pure 

cultures  of    this     microorganism  Fj^.  280.-Rhinophyma,  before  Operation. 

have  been  obtained  (P  a  1 1  a  u  f 

and  Eisenberg).  The  disease  has  been  produced  in  the  lower  animals 
by  inoculation  (Stepanow).  Free  excision,  in  the  early  stages,  is  the 
only  remedy. 

Rhinoph5rma. — This  is  a  name  applied  to  an  elephantiasis-like  thickening 
of  the  skin  of  the  nose,  in  which  all  of  its  structures  take  part.  Large  soft 
nodules  frequently  appear  on  the  alae  nasi  (Fig.  280).  Distinct  enchondromas 
have  been  found  in  this  situation. 

The  treatment  consists  in  reflecting  the  skin  covering  from  the  nodules  and 
remoA'ing  these,  the  skin  flaps  being  afterward  trimmed  and  replaced.  The 
removal  of  V-shaped  longitudinal  strips  the  entire  thickness  of  the  skin  serves 
to  reduce  the  nose  in  size  (Dieffenbach).  In  extreme  cases  the  entire 
integumentary  covering  of  the  nose  may  be  dissected  away  and  its  place  sup- 
plied by  Thiersch  skin  grafts.  The  result  as  shown  in  Fig.  281  was 
obtained  bv  a  combination  of  these  methods. 


502 


THE    SURGERY    OF   THE    HEAD 


Tumors  of  the  covering  of  the  nose  occur  in  the  shape  of  atheromas,  fibromas, 
and  adenomas  of  the  sweat-ghmds.  The  most  important  tumor  in  this  region, 
however,  is  epithelial  carcinoma.  The  latter  occurs  usually  as  a  flattened 
ulcer  and  differs  from  acne  and  lupus  in  selecting  primarily  by  preference  the 
alae  of  the  nose.  It  is  peculiar  in  that  it  rarely  passes  from  one  side  to  the 
other;  as  a  rule,  it  extends  outwardly  and  in  an  upward  direction.  It  usually 
remains  limited  to  the  integument  for  a  considerable  time.  The  lymphatics 
become  invoh-ed  late  in  the  affection;  therefore  early  extirpation  affords  a 
favorable   prognosis. 

In  addition  to  lupus  and  carcinoma,  syphilitic  ulceration  and  destruc- 
tion of  the  nose  may  occur.  In  the  differential  diagnosis  the  history  and 
the  results  of  microscopic  examination  must  here  be  the  main  reliance. 

Inflammations  of  the   Mucous   Membrane  of  the    Nose.— Chronic 

hypertrophic  rhinitis,  the 
thickening  being  particularly 
over  the  inferior  turbinated 
bones,  polypi,  and  ulceration 
may  result  from  repeated  at- 
tacks of  catarrhal  inflammation 
of  the  mucous  membrane  lining 
the  nose.  This  inflammation 
may  extend  to  the  frontal  sin- 
uses (page  515)  and  to  the  an- 
trum of  Highmore  (page  528). 

Ozena  results  from  an  ab- 
normal secretion  from  the  mu- 
cous glands,  the  peculiar  char- 
acteristic of  which  is  a  tendency 
on  the  part  of  this  secretion 
to  undergo  rapid  putrefactive 
changes.  It  is  not  infrequently 
associated  with  chronic  atro- 
phic rhinitis.  The  nasal  cavi- 
ties are  abnormally  large  in 
this  affection,  the  nasopharyn- 
geal region  and  orifices  of  the 
Eustachian  tube  being  visible  in 
exceptional  instances.  The  disease  may  be  preceded  by  the  hypertrophic 
form.  More  or  less  impairment  of  hearing  is  associated  with  atrophic  rhinitis 
in  about  two-thirds  of  all  the  cases.  A  pharyngitis  sicca  may  be  associated 
with  ozena  and  atrophic  rhinitis.  In  addition  to  the  putrid  odor,  the  charac- 
teristic feature  of  the  affection  is  the  presence  of  dried  crusts  on  the  mucous 
surface.     This  is  also  observed  in  pharyngitis  sicca. 

The  causes  of  ozena  are  obscure.  It  occurs  most  frequently  in  so-called 
scrofulous  subjects.  Syphilitic  disease  of  the  nose  should  not  be  confounded 
with  it.  Here  there  is  a  puriform  discharge  with  putrid  odor,  rather  than  a 
putrefaction  of  the  secretion  combined  with  the  accumulation  of  crusts.  The 
pressure  arising  from  these  crusts,  as  the  secretions  dry  on  the  surface  of  the 
mucous  membrane,  is  said  to  give  rise  to  disturbances  of  the  circulation  in 
the  parts  and  consequent  atrophy  (Bosworth). 


Fig.  281. 


-Rhinophyma.     The  Appearance  Presented 
AFTER  Operation. 


SOFT    PARTS    OF    THE    NOSE    AND    NASAL    CAVITIES  503 

The  treatment  consists  in  a  thorough  removal  of  the  crusts;  spraying  or 
syringing  the  mucous  membrane  with  a  cleansing  alkaline  and  antiseptic  solu- 
tion, *such  as  bicarbonate  of  soda,  gr.  ij;  borate  of  soda,  gr.  ij;  carbohc  acid, 
gr.  ij;  glycerin,  dr.  ij;  water,  oz.  j  (Do  bell);  this  is  followed  by  such 
applications  as  will  stimulate  the  secretion  of  mucus.  Of  these  may  be  men- 
tioned a  0.5  per  cent  solution  of  salicyhc  acid;  a  2  per  cent  solution  of  chlorate 
of  potash,  or  a  pledget  of  cotton  saturated  with  a  20  per  cent  solution  of  chlorid 
of  zinc  to  which  sufficient  hydrochloric  acid  has  been  added  to  make  a  clear 
liquid.  In  case  difficulty  is  experienced  in  loosening  the  crusts  by  means  of 
the  spray  apparatus,  pledgets  of  cotton,  upon  a  probe  and  saturated  with 
the  cleansing  agent,  are  to  be  passed  through  the  nasal  cavities  to  effect 
their  dislodgment. 

The  dailv  application  of  simple  cotton  plugs,  to  excite  the  secretion  of 
mucus,  has'  been  advocated  (Gottstein).  These  may  be  combined 
with  stimulating  medicaments  by  incorporating  certain  po\\  ders  in  the  cotton 
(Woakes).  lodol,  boric  acid,  or  aluminum  acetotartrate  are  very  use- 
ful, applied  in  this  manner.  The  treatment,  however,  involves  considerable 
discomfort  to  the  patient. 

Ulceration  of  the  mucous  membrane  frequently  results  from  acute  and 
chronic  rhinitis  and  from  too  persistent  efforts  to  dislodge  dried  secretions. 
These  frequently  show  but  slight  disposition  to  heal.  By  resisting  the  tenip- 
tation  to  remove  the  crusts  frequently,  and  occasionally  applying  white 
precipitate  ointment,  or  oxid  of  zinc  ointment,  the  healing  process  is  soon 
completed.  Syphilitic  rhinitis  in  the  newborn  may  be  associated  vith 
ulceration.  This  differs  from  that  resulting  from  the  common  form  of  rhinitis 
in  that  the  syphilitic  form  is  associated  with  periostitis  and  perichondritis  as 
well,  which  can  be  demonstrated  by  palpation  from  without,  the  external 
osseous  covering  also  being  invoh^d.  The  treatment  is  that  of  congenital 
syphilis  in  general,  namely,  appropriate  doses  of  gray  powder  or  inunction  of 
blue  ointment.  Syphilitic  affections  of  the  nose  will  be  discussed  on  page  508. 
The  ulceration  of  farcy  or  glanders  sometimes  occurs  in  the  nose;  it  is 
very  frequently  fatal.  It  is  usually  multiple,  occupies  both  nares,  and  is 
accompanied  by  swelling  of  the  skin  of  the  face  and  scalp,  vith  marked 
infiltration  of  the  subcutaneous  cellular  tissue.  The  occurrence  of  these 
symptom.s  in  conjunction  with  high  fever  and  the  presence  of  suppurative 
ulceration  of  the  nares  should  always  excite  suspicion  of  farcy.  Bacterio- 
logic  examination  will  assist  in  the  diagnosis  (see  page  32).  It  is  suggested, 
in  case  the  diagnosis  can  be  made  sufficiently  early,  to  expose  the  nasal,  cavities 
by  means  of  B  r  u  n  s  '  s  osteoplastic  resection  (page  507)  and  arrest  the 
propagation  of  the  infection  by  the  application  of  the  actual  cautery. 

Tumors  of  the  Mucous  Membrane  of  the  Nose. — Tumors  which  spring 
essentially  from  the  nasal  mucous  membrane  are  comprised  in  the  classes  loio^-n 
as  mucous  polypi,  papilloma,  and  the  rarely  encountered  epithelioma  and 
fibrosarcoma.  Tumors  which  invade  the  nasal  cavity  from  other  regions  will 
be  considered  in  connection  with  the  surgerA'  of  those  regions  (tumors  of  the 
upper  jaw,  of  the  pteiygopalatine  fossa,  and  of  the  base  of  the  skull). 

The  mucous  polypi  are  the  most  frequently  seen  of  all  tumor  formations 
of  the  nose.  They  result  from  repeated  attacks  of  rhinitis;  they  have  also 
been  observed  in  connection  with  tumors  springing  from  the  upper  jaw  and 
the  base  of  the  skull. 


504  THE  SURGERY  OF  THE  HEAD 

Mucous  polj'pi  are  of  a  soft  consistency,  almost  gelatinous  at  times,  and  a 
pale  grayish-yellow  color,  not  unlike  the  ocean  polypi.  Microscopicalh'  they 
consist  of  a  development  of  the  mucous  glands  and  submucous  connective 
tissue;  the  cells  are  few  in  number  and  are  surrounded  by  an  almost  homo- 
geneous matrix.  Pathologically,  they  are  benign  adenornyxomas  of  the 
mucous  membrane.  The  great  majority  of  these  tumors  take  their  origin  from 
the  mucous  membrane  covering  the  turbinated  bones,  particularly  the  middle 
and  nasal  meatus.  Less  frequently  the}^  originate  from  the  free  posterior  edge 
of  the  septum  and  hang  down  behind  the  soft  palate.  Rarelj'  they  are  found  to 
spring  from  the  mucous  membrane  covering  of  the  ethmoid  bone.  Their 
growth,  except  in  the  case  of  those  at  the  posterior  edge  of  the  septum,  tends 
at  first  to  bring  them  forward  toward  the  anterior  nares.  Subsequently,  they 
grow  posteriorly  and  may  even  appear  at  the  posterior  nares  or  in  the  pharyn- 
geal cavity.  In  this  location  a  digital  examination  mil  reveal  their  presence. 
The  anterior  extremity  of  a  polypus,  if  well  forward  in  the  nasal  cavity,  is  prone 
to  ulceration.  As  a  result  of  constant  irritation  and  chronic  inflammatory 
action,  the  tumor  may  become  more  or  less  indurated  and  thickened.  Under 
these  circumstances,  also,  hemorrhage  is  of  occasional  occurrence. 

Mouth-breathing  results  from  an  occlusion  of  the  nostrils  from  the  presence 
of  polypi,  and  as  a  result  of  chronic  thickenings.  This,  in  its  turn,  may  lead  to 
diseases  of  the  pharynx,  larynx,  bronchi,  and  lungs.  Asthmatic  troubles  are 
also,  in  some  instances,  traceable  to  intranasal  disease.  The  sense  of  smell  is 
weakened  and  the  formation  of  vowel  sounds  greatly  impaired ;  to  the  latter, 
a  nasal  sound  is  added.  Large  polypi  occupying  both  nasal  cavities  may 
produce  marked  deformity  of  the  face.  In  the  diagnosis  of  polypi  care  must 
be  taken  not  to  mistake  for  these  growths  the  chronic  hypertrophic  conditions 
of  the  mucous  membrane  covering  the  turbinated  bones,  particularly  that 
covering  the  anterior  edge  of  the  inferior  turbinated  bone.  The  grayish 
color  of  the  latter  compared  with  the  bright  red  color  of  the  former,  together 
with  the  fact  that  polypi  are  usually  more  or  less  pedunculated  while  simple 
hypertrophies  are  sessile,  wdll  serve  to  distinguish  the  one  from  the  other. 

Papilloma  is  a  comparatively  rare  affection  of  the  mucous  membrane. 
It  consists  of  a  warty  growth,  situated,  in  the  case  of  the  soft  variety,  which 
is  the  more  common  on  the  inferior  turbinated  bone;  the  hard  papil- 
loma occurs  near  the  mucocutaneous  junction  and  ma}^  spring  from  the 
septum,  floor,  or  inner  surface  of  the  ala.  It  is  usually  sessile  in  character. 
It  gives  rise  to  no  particular  disturbance  until  it  has  attained  a  considerable 
size.  Hemorrhage  may  occur  if  erosion  of  the  growth  takes  place.  The 
treatment  consists  in  extirpation  with  the  cold  snare,  with  or  Avithout  the 
application  of  the  galvanocautery  to  the  base.  In  case  of  very  large 
papilloma  an  external  operation  (W  a  r  cl ,  V  e  r  n  e  u  i  1) ,  such  as  tem- 
porary resection  of  the  nose  (B  r  u  n  s  ,  page  507) ,  may  be  necessary. 

The  Operative  Treatment  of  Nasal  Polypi. — The  only  successful  means 
of  dealing  with  these  growths  is  their  extirpation.  The  use  of  the  forceps  for 
this  purpose  has  now  ver}^  largel}^  given  way  to  that  of  the  cold  wire  snare 
ecraseur,  J  a  r  v  i  s  (Fig.  282).  This,  or  one  of  its  modifications,  is  mounted 
with  fine  unannealed  steel  piano  wire,  which  gives  it  a  certain  amount  of  stiffness 
and  enables  the  operator  after  a  little  practice,  to  place  the  loop  in  any  desired 
location  or  position.     This  being  accomijlished,  the  encircled  portion  of  the 


SOFT   PARTS    OF   THE    NOSF    AXD    NASAL    CAVITIES 


505 


tumor  is  severed  from  its  attachment.  Instruments  designed  to  accomplish 
the  tightening  of  the  loop  A\ith  but  a  single  movement  of  one  hand  are  pref- 
erable. The  galvanocautery  loop  (M  i  d  d  e  1  d  o  r  p  f  and  V  o  1 1  o  1  i  n  i 
is  now  seldom  used  by  operators  of  experience.  This  cauterization,  as  well 
as  the  barbarous  procedure,  formerly  practised,  of  removal  of  a  portion  of  the 
turbinated  bone  attached  to  the  growth,  is  imnecessary. 

Cocain  anesthesia  should  always  precede  the  operation  for  rem^oval  of 
polypi.  A  freshl}^  made  20  per  cent  solution,  thrown  into  the  nose  b\  means 
of  a  spra}-  apparatus,  should  be  used;  this  produces  insensibility  both  rapidly 
and  completely.  Large  growths  are  difficult  to  cocainize,  but  by  persisting, 
anesthetization  may  be  finally  accomplished.  A  portion  of  the  growth  being 
removed,  a  fresh  supply  of  the  cocain  solution  should  be  introduced.  It  is 
not  always  possible  to  encircle  the  entire  growth  at  the  first  attempt.  The  loop 
should  be  passed  between  the  septum  and  the  growth  with  its  lo^^'er  border 
below  the  level  of  the  tumor,  when  it  should  be  turned  to  a  horizontal  position 
(inasmuch  as  in  the  great  majority  of  cases  the  grovi;h  is  attached  to  the  middle 
turbinated  bone),  and  by  gentle  manipulation  slipped  in  an  upward  direction 
until  as  much  of  the  growth  as  it  is  possible  to  grasp  is  judged  to  be  within  its 
opening.  The  loop  should  now  be  forcibly  tightened,  the  instrument  being  held 
steadily;  the  process  is  really  a  cutting  one.     If  an  exostosis  of  the  septum  pre- 


FiG.  282. — Jarvis's  Sxare. 


vents  the  proper  introduction  of  the  wire  loop,  this  should  be  removed  (vide 
infra) .  Several  sittings,  as  a  rule,  are  necessary,  and  in  order  to  guard  against 
further  growth  the  case  should  be  kept  under  observation  for  several  months. 

Osteoma. — AA^iile  it  is  not  a  specially  rare  occurrence  for  bony  tumors 
that  have  their  origin  in  other  parts  to  invade  the  nasal  cavity,  a  growth  of 
this  nature  occurring  primarily  in  the  latter  region  is  of  infrequent  occurrence. 
These  tumors  are  among  the  nasal  growths  first  described  by  the  earliest  T\Titers 
on  medicine.  Their  etiology  is  obscure.  They  occur  early  in  life,  say  from  the 
age  of  fifteen  to  twenty;  a  case  making  its  first  appearance  at  forty-five  is 
recorded,  however  (Tillmanns).  The  male  sex  seems  to  be  attacked 
by  preference. 

External  deformity  is  usually  noticed  before  the  occurrence  of  nasal  stenosis, 
owing  to  the  fact  that  the  osseous  growth  has  its  origin  in  the  upper  portion 
of  the  nasal  cavity,  and  extends  toward  the  face  rather  than  in  a  do^mward 
direction  toward  the  lower  meatus.  The  orbit  may  be  invaded,  the  tumor 
extending  through  the  ethmoid  cells.  Pain  may  be  present,  due,  in  great 
part  at  least,  to  pressure  on  some  of  the  sensory  nerves.  Epistaxis  is  not  of 
frecjuent  occurrence.  Any  discharges  from  the  nose  that  take  place  are  due 
to  ulceration  or  necrotic  changes  in  the  tumor.  The  latter  may  lead  to 
external  fistulous  openings. 


506 


THE    SURGERY    OF   THE    HEAD 


These  growths  have  their  origin  in  the  periosteum  and  general!}^  spring 
from  one  of  the  accessory  sinuses.  The  ethmoid  cells  give  rise  to  them  in 
the  majority  of  instances,  though  they  may  spring  from  the  septum  or  in- 
ferior turbinated  l)ones.  Their  surface  is  irregularly  lobulated  and  covered 
with  mucous  membrane.  Their  external  bony  surface  is  compact,  while  the 
interior  is  composed  of  cancellous  tissue. 

The  osteomas  are  sometimes  distinguished  as  the  hard  and  the  soft  variety, 
though  this  division  is  misleading  from  the  fact  that  they  are  all  hard  to  the 
touch.  The  division  is  based  on  the  relative  amount  of  compact  and  cancellous 
tissue  which  goes  to  make  up  the  tumor.  Osteoma  can  be  mistaken  only  for 
osteosarcoma.  The  history  of  the  growth,  and,  in  case  of  doubt,  the  removal 
of  a  portion  for  microscopic  examination,  will  determine  the  cpestion. 

The  treatment  consists  in 
extirpation.  An  external  opera- 
tion, in  order  to  reach  the  place 
of  attachment  of  the  growth,  will 
usually  be  necessary  {vide  infra). 
This  must  be  planned  in  accord- 
ance with  the  demands  of  indi- 
vidual cases.  Osteomas,  attached 
to  the  septum  or  inferior  turbi- 
nated bone,  may  occasionally  be 
reached  and  removed  by  means 
of  the  nasal  saw  without  external 
operation. 

Enchondroma. — This  is  a  very 
rare  affection,  if  the  term  is  re- 
stricted, as  it  should  be,  to  the 
large,  round,  nodulated  tumor 
which  presents  all  the  clinical  fea- 
tures of  fibroma,  but  which  on 
removal  is  found  to  contain  hya- 
line cartilage.  The  nasal  cavi- 
ties do  not  present  favorable  con- 
ditions for  the  development  of 
cartilaginous  tissue.     The  symp- 

FiG.  283.— Skin  Incision  for  Splitting  the  Nose.  ^OmS  are   SUch  aS  are  met  with  in 

fibroma,  namely,  nasal  stenosis 
and  mucopurulent  discharge;  the  latter  may  be  offensive  as  the  result  of 
retention.  The  slow  growth  of  enchondromas,  their  great  density,  immobility, 
pinkish-yellow  color,  and  nodulated  appearance,  together  with  their  loca- 
tion, which  is  usually  the  point  of  junction  of  the  septum  with  one  of  the 
alar  cartilages,  serve  to  distinguish  them  from  the  nasal  gro^^■ths  and  from 
deviations  of  the  septum.     They  usually  occur  in  young  subjects. 

The  method  of  removal  is  to  be  determined  by  the  size  and  situation  of 
the  growth.  Either  the  cold  snare,  the  curet,  or  the  gouge  may  be 
employed.     They  show  no  tendenc}'  to  recurrence. 

Osteoplastic  Resection  of  the  Nose. — The  complete  removal  of  intra- 
nasal tumors  may  demand  the  exposure  of  these,  together  with   the  nasal 


SOFT   PARTS    OF    THE    NOSE    AND    XASAL    CAVITIES 


507 


The  simplest  of  these  operations  con- 


FiG.  284. — Langenbeck's  Line  of  Incision  for 
Osteoplastic  Resection  of  the  Nose. 


cavities,  through  an  external  operation. 

sists  in  splitting  the  nose  in  the  me- 
dian line  (Fig.  283),  from  one  or  the 

other  nasal  orifice  to  the  nasal  bones. 

Though  the  deformity  following    this 

operation   is   not   great,   it   does   not 

give  access  to  any  point  be}-ond  the 

anterior  nasal  fossae. 

Langenbeck's  operation  consists 

of  a  temporary  resection  of  the  bony 

lateral  wall  of  the  nose.     The  incision 

is   commenced    in    the    median    line 

slightly  above    tlie   root  of   the  nose 

and  is   carried  directly  downward  in 

the  median  line,  reaching  to  the  ala. 

Another  incision,  commencing  at  the 

inner  cavities  of  the  eye  and  extend- 
ing  do\Mi'ward,    parallel  to    the   first 

and    corresponding   to    the    posterior 

border   of   the   nasal   bone,    likewise 

extends  to  the   ala  nasi.     These  two 

incisions   are   joined   by  a  horizontal 

one  at  their  lower   extremities  (Fig. 

284).     Bv  means  of   a  pair  of   bone- 
cutting  forceps   the  bone  is   di\'ided  along  the  vertical  lines  of  incision  and 

the  osteocutaneous  flap  turned  upward. 

Oilier' s  Operation. — The  design  in  this  operation   is  to  detach  the  bony 

framework  of  the  nose  from  the  face 
and  turn  it  downward.  Two  inci- 
sions, one  on  each  side  of  the  nose 
and  at  its  junction  with  the  cheek, 
are  made.  These  extend  to  the  alae 
of  the  nose.  A  shghtly  cur\'ed  trans- 
verse incision  connects  them  above 
(Fig.  285).  By  means  of  a  thin- 
bladed  narrow  saw,  section  of  the 
bone  and  septum  is  made  along  the 
same  Imes.  The  nose,  thus  freed 
from  its  attachments,  is  tilted  do's^m- 
ward  on  the  face.  This  operation 
gives  access  to  the  nasal  cavities  and 
nasopharyngeal  space. 

Bruns's  Operation. — In  this  pro- 
cedure the  first  incision  is  commenced 
immediatelv  below  the  outer  margin 
of  the  nostril  on  the  sound  side,  and 
is  carried  in  a  horizontal  line  directly 

T,     r,^^    r^        ,  r  T  r^  across  to  from  half  to  three-fourths  of 

xiG.  2«5. — Olliers  Line  OF  Incision  FOR  Osteo-  ...  .... 

plastic  Resection  of  the  Nose.  an  mch  DCVOnd  the  OUter  Imilt  of   the 


508 


THE    SURGERY    OF    THE    HEAD 


Fig.  286. — The  Line  of  Incision  for   Bruns's 
Osteoplastic  Resection  of  the  Nose. 


other  nostril.     This  is  carried  directly  down  to  the  bone,  but  does  not  invade 
the  cavity  of  the  mouth.     A  second  horizontal  incision  is  made  across  the 

bridfj;o  of  the  nose  at  its  narrowest 
part,  from  one  inner  canthus  to  the 
other.  These  two  incisions  are  joined 
by  a  third,  vertically  placed,  at  the 
junction  of  the  nose  and  cheek  (Fig. 
286) .  A  thin-bladed  saw  is  now  in- 
troduced at  the  point  of  commence- 
ment of  the  first  incision  and  made 
to  enter  the  nasal  cavity.  The  first 
section  made  by  the  saw  is  through 
the  anterior  nasal  spine  and  septum; 
the  instrument  is  then  carried  around 
the  entire  extent  of  the  original  lines 
of  incision.  The  free  end  of  the  saw 
plays  in  the  nasal  cavity  throughout 
the  entire  extent  of  the  section  of 
bone;  its  tilted  position  makes  a  bev- 
eled cut.  The  bony  section  is  con- 
fined entirely  to  the  superior  maxilla, 
the  anterior  portion  of  the  inferior 
turbinated  bone,  and  the  bony  sep- 
tum, the  latter  being  divided  last  from  below  upward  by  means  of  a  pair  of 
bone  forceps.  The  entire  nose  is  now 
turned  to  one  side  (Fig.  288). 

The  best  of  these  operations  is  that 
of  B  r  u  n  s  .  It  is  comparatively  easy  of 
performance,  and  by  means  of  it  wide 
access  is  gained,  not  only  to  the  nasal 
passages,  but  to  the  nasopharynx  as  well. 
In  all  of  the  operations  of  osteoplastic 
resection  of  the  nose,  when  the  indica- 
tions for  which  the  operation  was  per- 
formed have  been  accomplished,  the 
parts  are  restored  to  their  normal  posi- 
tion and  there  sutured. 

The  position  of  the  head  during  these 
operations  is  of  importance.  That  of 
Rose,  with  the  head  in  a  dependent 
position  over  the  edge  of  the  table,  has 
some  advantages  (see  page  534  ) .  Plug- 
ging the  posterior  nares,  to  prevent  the 
blood  from  passing  into  the  larynx,  or 
preliminary  tracheotomy  and  the  use  of 
Trendelenburg's  cannula,  may 
also  be  employed. 

Syphilitic    Affections    of   the   Nose. — The    osseous    and    cartilaginous 
structures  of  the  nose  are  preeminently  disposed  to  syphilitic  affections.     A 


Fig.  287. — Osteoplasty  after  Bruns. 
Showing  the  skull  lines  of  section. 


SOFT   PARTS    OF   THE    NOSE    AND    NASAL    CAVITIES 


509 


favorite  starting-{)()int  for  these  is  the  i^eriosteiun  of  the  septum,  though  the 
alae  nasi  and  anterior  edge  of  the  septum  may  become  affected.  In  the  latter 
case  a  poricliondrial  infiltration  first  occurs,  followed  by  suppurative  destruction 
of  the  cartilages.  The  foci  of  infection  on  the  bony  septum  frequently  lead  to 
perforation  of  the  latter.  The  spread  of  the  destructive  process  leads  to  a 
sinking  in  of  the  entire  nasal  bony  framework,  producing  a  characteristic 
deformity.  This  sunken  appearance  of  the  nose  may  vary  from  a  slight 
depression  of  the  bridge  to  a  complete  flattening. 

The  bony  framework  of  the  nose  is  occasionally  the  seat  of  necrosis  in 
laborers  employed  in  chemical  factories  in  which  potassium  salts,  arsenic,  and 
corrosive  sublimate  are  made. 

The  skin  of  the  nose  is  rarely  the  seat  of  S3^philitic  affections;  if  these  occur 
at   all,   it   is  late  in   the  destructive 
process,  and  they  are  the  result  of  ex- 
tension from  within,  particularly  from 
the  septum. 

Syphilitic  disease  of  the  nose  is  to 
be  treated,  at  first,  on  an  antisyph- 
ilitic  basis.  Subsequently  when  the 
destructive  process  has  terminated, 
plastic  operative  procedures  are  indi- 
cated to  overcome  existing  deformities 
(vide  infra). 

Tuberculous  Affections  of  the 
Nose.  —  Subperichondrial  abscess 
of  the  nose  may  occur  in  strumous 
children.  These  occur  bilaterally,  as 
a  rule,  the  swelling  closing  the  nos- 
trils like  a  tumor  of  the  septum. 
Fluctuation  is  easily  discovered  and 
a  free  incision  will  give  exit  to  the 
pus.  As  a  rule,  perforation  of  the 
septum  has  taken  place,  but  the  peri- 
chondrium closes  this  in  and  the 
opening  is  not  permanent,  as  in  syphilis, 
pus,  but  is  sometimes  light  and  viscid. 

Tuberculous  ulceration  and  granulating  proliferative  processes  may 
attack  the  nose,  the  latter  process  occurring  particularly  at  the  septum. 


Fig.  a 


— Bruns's  Method  of  Osteoplastic 
Resection  of  the  Nose. 


The  evacuated  fluid  is  not  always 


RHINOPLASTY 

This  operation  is  performed  for  deformities  that  are  the  result  of  the  fol- 
lowing : 

1,  Destruction  of  a  portion  or  all  of  the  bony  framework  of  the  nose  and 
adjacent  osseous  structures.  Complete  destruction  of  the  bony  framework 
usualh'  results  from  syphilis,  and  rarely  from  tuberculous  disease.  Loss  of 
portions  of  the  nasal  bony  structure  is  due  to  suppurative  processes  following 
injuries.  Depressed  fractures,  giving  rise  to  the  deformity  kno\\Ti  as  "saddle 
nose,"  also  require  a  rhinoplastic  operation. 


510 


THE    SURGERY    OF   THE    HEAD 


2.  Partial  loss  of  both  bone  and  soft  parts,  caused  by  sj'philis,  lupus,  and 
carcinoma.  It  may  likewise  follow  injuries.  The  procedure,  under  these 
circumstances,  is  kno^^Ti  as  partial  rhinoplasty. 

3.  Complete  loss  of  the  organ  resulting  from  saber  cuts,  shell  and  gunshot 


H 


Fig.  289. — Konig's  Osteoplastic  Rhinoplasty. 
A,  The  upturned  tip  of  the  nose  restored  by  a  transverse  incision ;   the  lines  for  the  osteoplastic  bridge 
and  the  integumentary  flap  appear  on   the  forehead;   B,  the  osteoplastic  bridge  in  place;   C,  the  flap  with 
pedicle,  taken  from  the  forehead,  sutured  in  position. 


Fig.  290. — Partial  Rhinoplasty. 
A,  Rectangular  flap  from  healthy  part  of  nose ;   B,  rectangular  flap  from  healthy  part  of  nose  covering  the 

defect. 


wounds,  etc.     The  operation  intended  to  correct  the  resulting  deformity  is 
known  as  complete  rhinoplasty. 

Operation  for  Saddle  Nose.— The  underlying  principle   of  these  oper- 
ations is  that  of  transplantation  of  a  flap  consisting  of  both  bone  and  skin 


SOFT   PARTS    OF    THE    XOSE    AND    XASAL    CAVITIES 


511 


* 


Fig.  291. — Busch's  Method  of  Rhixopl.\stt. 

Flap  used  to  cover  the  defect  when  the  septum  and  the 

tip  of  the  nose  are  absent. 


taken  from  the  forehead  to  fill  the  gap  in  the  bridge  of  the  nose  that  has  re.sulted 
from  freeing  the  tip  and  restoring  it  to  its  proper  position  (Konig).  The 
bony  portion  of  the  flap  furnishes  a  rigid  support  to  prevent  the  soft  parts  from 
again  collapsing.  In  K  o  n  i  g  '  s 
original  operation  a  transverse 
incision  is  employed  to  free  the 
upturned  tip  and  permit  its  re- 
storation. The  resulting  gap, 
which  opens  into  the  nasal  cav* 
ity,  is  filled  with  an  osteoplastic 
flap,  the  base  of  which  is  at  the 
root  of  the  nasal  bridge.  This 
flap  is  about  two  and  one-half 
inches  long  and  three-eighths  of 
an  inch  wide.  It  is  formed  by 
two  vertical  parallel  incisions 
extending  from  the  root  of  the 
nose  and  united  at  their  upper  ex- 
tremities (Fig.  289).  The  inci- 
sions are  carried  directly  to  the 
bone.  A  narrow  groove  corre- 
sponding to  the  incisions  in  the 
soft  parts  is  chiseled  in  the  bone, 
extending  to  the  diploe.  The 
outer  surface  is  now  separated 

from  the  diploe,  with  a  flat   chisel,  do^^TL  to  its  base,  broken  across   at  this 
point,  and,  together  with  its  skin  covering,  inserted  so  that  the  latter  presents 

to  the  nasal  cavity.  The  lower 
edge  of  the  inverted  flap  is  slipped 
under  the  skin  edge  of  the  lower 
margin  of  the  original  transverse 
incision  and  there  sutured.  The 
outer  or  raw  presenting  surface  of 
the  bony  portion  of  the  flap  is 
covered  by  a  pediculated  flap 
fashioned  from  the  skin  of  the 
forehead.  This  is  brought  do^^^l 
into  position  by  reversing  its  sur- 
face through  a  half  tudst  at  the 
base  of  the  pedicle,  and  sutured  in 
place.  The  gaps  in  the  forehead 
are  closed  at  once  as  much  as  pos- 
sible. The  pedicles  are  divided 
when  union  has  taken  place.  The 
protuberances  left  by  the  pedicles 
of  the  reversed  flaps,  together  with 
the  remaining  openings  in  the  soft  parts  in  the  same  situation,  are  corrected 
at  a  subsequent  operation.  Israel  and  H  e  1  f  e  r  i  c  h  employ  a  curved 
incision  with  its  convexity  upward  to  free  the  top,  make  the  bone  flap  less 


Fig.  292. — Partial  Rhinoplasty. 
Method  of  correcting  a  defect  of  the  ala  nasi. 


512 


THE    SURGERY    OF    THE    HEAD 


Fig.  293. — Parti.^l  Rhinoplasty. 

Another  method   of   correcting  a  defect  of  the   ala 

nasi. 


than  one-fourth  of  an  inch  wide,  clo.se  the  .2;ap  in  the  forehead  by  suturing, 
and  leave  the  outer  presenting  surface  of  the  inverted  flap  to  cicatrize.  When 
healing  has  taken  place,  the  unsightly  lump  at  the  base  is  dispo.sed  of  by  mak- 
ing flaps  from  the  skin  beneath  the  turned  over  base  of  the  flap  and  bringing 

tliese  over  to  recover  the  new  nasal 
bridge,  whose  cicatricial  covering  is 
dissected  away  for  that  purpose. 
S  c  h  i  m  m  e  1  b  u  s  c  h  formed  a  flap 
of  skin  and  bone  with  narrow  pedi- 
cle and  broad  base,  and  closed  the 
forehead  defect  by  sliding  large 
cur\-ed  flaps.  The  flap  is  not  tran.s- 
planted  until  its  parts  are  well  con- 
solidated, this  usually  occupying  a 
period  of  several  weeks.  Several 
operations  are  reciuired  to  give  a 
good  result,  which,  however,  is  finally 
obtained  (see  Complete  Rhino- 
plasty) . 

Attempts  to  transplant  detached 
plates  of  bone  from  the  tibia,  decal- 
cified bone,  etc.,  are  not  successful 
for   the    reason    that    the    posterior 

surface  is  exposed  in  the  nasal  cavity  and  leads  to  suppuration  and  loss  of 

the  bony  plate.     In  comparatively  slight  deformities  in  which  restoration  can 

be  effected  without  opening  the  nasal  cavity  they  have  succeeded  (Lexer). 

The   subcutaneous   injection  of 

parajfin    has    been    followed    by 

thrombosis  accidents  resulting  in 

total  blindne.ss. 

D  a  w  b  a  r  n  operates  for  the 

correction   of   nasal  bony  defects 

as  follows:  Dentist's  gutta-percha 

is  softened  over  an  alcohol  lamp 

and  molded  over  the  nose  until  it 

fits  the  deformity  and  corrects  it. 

It  is  then  hardened  by    cooling. 

The   patient  is  then  anesthetized 

and    each    nostril    packed    with 

gauze  well  back  to  pre\'ent  blood 

from  flowing   into    the    phar\'nx. 

A  knife  is  then  inserted  into  the 

nostril  and  the   skin  and   perios- 
teum stripped  from  the  nasal  bone 

on  the  side  of  the   deformity  as 

widely  as  possible,   care   being  taken  to  avoid    the   infraorbital  vessels.     In 

the  case  of  a  centrally  placed  or  bilateral  deformity  it  is  necessarv  to  enter 

both  nostrils.     The  cavity  thus  formed  is  packed  until  bleeding  is  arrested, 

when  the   molded   piece   of  gutta-percha  is   slipped  in  through  the  incision 


Fig.   294. — Pai;tial  Rhinoplasty. 

K6nig'.s  operation  for  correcting  a  defect  of  the  ala  na.si 

by  transplanting  a  piece  from   the  auricle. 


SOFT  PARTS  OF  THE  NOSE  .VXD  NASAL  CAVITIES 


513 


until  it  occupies  the  site  of  the  deformity  and  corrects  it.  The  piece  of 
giitta-pcrcha  is  held  in  place  by  a  small  roller  bandage  compress  on  each  side 
of  the  nose,  and  a  strip  of  surgeon's  plaster.  D  a  w  b  a  r  n  claims  that 
gutta-porcha  does  not  produce  irritation,  remains  unchanged,  and.  even  if 
suppuration  takes  place,  this  soon  subsides,  and  the  gutta-percha  heals  in. 


Fig.  295. — ScHiiiitELBUscn's  Complete  Rhixoplastt. 
A.  Osteoplastic  flap  detached  from  the  forehead. 
1,  1,  Areas  of  skin  removed  to  permit  the  sliding  of  the 
lateral  flaps  in  position.  The  dotted  lines  about  the  re- 
mains of  the  alae  nasi  show  the  site  of  the  incisions  for  the 
formation  of  the  newcolmnna.  B.  The  osteoplastic  flap 
covered  "with  Thiersch  skin  grafts  and  reversed.  The 
newly  formed  columna  is  shown  in  position.  2.  2,  Lat- 
eral skin  flaps  approximated.  C.  Osteoplastic  flap 
sutured  in  place  and  the  pedicle  severed.  The  stump 
of  the  pedicle  Ls  sutured  to  the  freshened  edges  of  the 
defect  in  the  glabella  region. 

Partial  Rhinoplasty.  —  Partial  de- 
fects are  best  corrected  by  oblic^uely 
placed  and  pediculated  skin  flaps  taken 
either  from  the  forehead  or  from  some 
other  adjacent  structure,  according  to 
the  location  of  the  defect  (Fig.  290),  care 
being  exercised  to  have  these  sufficiently 
large  to  provide  skin  to  line  the  edge  of 
the  newly  formed  ala  nasi.  The  new  de- 
fect is  closed,  except  the  opening  left  for 
the  replacement  of  a  part  of  the  pedicle  where  the  latter  is  subsequently 
detached. 

Complete  Rhinoplasty. — K  6  n  i  g  '  s  method  of  transplantation  of  an 
osteoplastic  flap  from  the  forehead  is  modified  and  adapted  to  complete 
rhinoplasty.  The  flap  of  the  skin  and  bone  is  cut  one  and  one-half  inches 
vdde.  inverted  at  its  base  at  the  root  of  the  nose,  and  placed  temporarily  over 
the  defect.  After  several  weeks  it  becomes  thorouglily  consolidated  by  the 
34 


514  THE  SURGERY  OF  THE  HEAD 

reparative  process.  It  is  then  divided  longitudinally  in  three  sections  with 
a  fine  saw.  The  middle  section  serves  for  the  new  bridge  of  the  nose.  The 
lateral  sections  are  separated  from  their  connections  above,  but  still  remain 
attached  at  the  lower  end.  These  are  turned  doA\Tiward  and  outward  at  an 
angle  so  as  to  form  a  bon}^  tripod  to  support  the  tip  of  the  new  nose.  The 
outer  surface  is  freshened  and  covered  by  skin  from  the  lateral  margins 
of  the  original  defect  (Rotter).  Or  S  c  h  i  m  m  e  1  b  u  s  c  h  '  s  plan  of 
dividing  the  bone  in  the  center  and  utilizing  each  half  to  form  bony  walls  for 
the  new  nose  in  its  entire  length  may  be  followed.  In  this  method  a  large 
flap  is  taken  from  the  forehead  in  the  same  manner  as  in  the  operation  for 
saddle  nose.  The  base  of  this  flap  before  it  is  inverted  is  from  three-fourths 
of  an  inch  to  an  inch  wide  and  its  upper  end  from  two  to  two  and  one-fourth 
inches  wide.  The  defect  in  the  forehead  is  closed  at  once  by  a  plastic  proce- 
dure (Fig.  295,  A).  After  the  separation  of  such  necrotic  portions  of  the  bone 
as  fail  to  survive  (usually  from  four  to  eight  weeks  afterward),  the  granulating 
surface  of  the  flap  is  covered  by  Thiersch's  strips.  When  the  heal- 
ing of  these  is  completed,  the  flap  is  sawed  lengthwise  to  the  depth  of  its  bony 
portion  so  that  it  can  be  shaped  like  a  double-pitched  roof  (Fig.  295). 

The  flap  must  now  be  reversed.  This  is  done  by  loosening  the  pedicle  so 
that  a  half-turn  can  be  made  in  it.  By  this  maneuver  the  normal  skin  aspect 
of  the  flap  looks  outward,  and  the  Thiersch-covered  side  presents  inward,  or 
toward  the  nasal  cavity.  The  edges  of  the  defect,  both  bony  and  soft,  are 
now  freshened,  and  to  these  the  freshened  edges  of  the  bony  flap  are  adapted 
and  sutured.  Where  sufficient  tissue  is  present,  a  new  columna  may  be  formed 
(Fig.  295,  B).  In  order  to  obviate  the  tendency  of  the  new  bony  lateral  walls 
to  spread,  and  at  the  same  time  to  provide  for  the  normal  depressions  on  each 
side  above  the  nostrils,  a  silver  wire  is  passed  through  from  side  to  side  and 
twisted  over  pieces  of  rubber  tubing.  Finally,  when  union  of  the  flap  is 
assured,  the  pedicle  is  severed.  Reposition  of  the  stump  left  is  effected  by 
suturing  it  to  the  freshened  region  of  the  glabella.  The  construction  of  a  sep- 
tum is  useless  as  far  as  aiding  to  maintain  the  shape  of  the  tip  is  concerned. 
A  celluloid  support  or  silver  double  tube  answ^ers  the  purpose  much  better. 
Eventually  this  need  be  worn  only  at  night. 


THE  FRONTAL  SINUSES 

These  are  accessory  to  the  nasal  cavity,  with  which  they  communicate 
through  the  infundibulum.  They  are  situated  one  on  each  side  of  the  nasal 
spine,  between  the  two  tables  of  the  frontal  bone,  and  are  separated  from  each 
other  by  a  thin  bony  partition  and  from  the  cranial  cavity  by  a  thin  bony  wall 
which  is  continuous  with  the  internal  table  of  the  rest  of  the  skull  (Fig.  296). 
They  are  absent  at  birth,  but  appear  in  early  childhood.  Up  to  puberty  they 
remain  of  small  size,  when  they  enlarge  coincidentally  with  recession  of  the 
brain.  They  are  lined  with  mucous  membrane  which  is  continuous  AA'ith  that 
hning  the  nasal  cavity  through  the  infundibulum. 

Injuries. — These  are  usually  the  result  of  direct  violence,  such  as  knife 
thrusts,  sword  cuts,  projectiles,  flying  fragments,  horse  kicks,  blows  of  the  fist, 
falls  on  the  face,  and  the  hke.     The  resulting  lesions  are  generally  those  of 


THE    FRONTAL    SINUSES 


515 


fracture,  either  a  simple  fissure  with  or  ^^•ithout  indentation,  a  compound 
comminuted  fracture,  or  a  punctured  fracture.  These  injuries  occur  almost 
invariabh'  in  the  anterior  wall.  Fractures  of  the  cranial  wall  are  quite 
generally  fatal.     Hematoma  of  the  sinus  usually  coexists. 

The  symptoms  are  either  local  or  cerebral,  or  both.  Epistaxis  and  pain 
are  practically  the  only  symptoms  present  in  simple  fracture.  The  epistaxis 
may  be  absent  in  compound  fracture.  The  lining  membrane  of  the  injured 
smus  is  sometimes  detached.  The  escaping  secretion  may  simulate  brain 
substance.  Subcutaneous  opening  of  the  sinus  may  lead  to  adjacent  subcu- 
taneous emphysema  (pneumatocele).  Infection  of  the  injured  parts  readily 
follows  exposure  of  the  cavity  of  the  sinus,  and  abscess,  periostitis,  necrosis 
fistula,  and  intracranial  complications  may  result.  In  the  absence  of  in- 
fection, healing  is  the  rule.  Hemorrhage  from  the  sinus  in  simple  fracture 
may  sometimes  be  detected  by  rhinoscopic  examination.  Sinusitis  with 
empyema  of  the  frontal  sinus  may 
follow  undetected  fractures  or  simple 
contusions. 

Treatment. — In  all  open  injuries  an- 
tiseptic irrigation  and  drainage  must  be 
practised.  The  possibility  of  intracra- 
nial complications  should  be  borne  in 
mind.  The  opening  should  be  enlarged, 
the  sinus  thoroughly  cleansed,  spiculas 
of  bone  and  foreign  bodies  removed, 
the  cranial  wall  examined  for  possible 
injury,  and  the  cavity  drained.  In 
very  extensive  wounds  a  subsequent  plastic  operation  may  be  re- 
quired. Pneumatocele  is  best  treated  by  the  application  of  a  bandage  and 
compression. 


Fig.    296. —  Horizontal    Section    through 

THE  Frontal  Sinus. 

1,  Frontal    bone;    2,    frontal  sinus;    3,  frontal 

aperture ;  4,  frontal  septum ;  5,  crista. 


INFLAMMATION  OF  THE  FRONTAL  SINUS  (FRONTAL  SINUSITIS) 

This  may  be  either  acute  or  chronic.     The  acute  form  generally  results  from 
a  coryza,  particularly  in  epidemic  influenza. 

Symptoms.— These  include  headache,  sometimes  accompanied  by  fever, 
vertigo,  vomiting,  etc.  Ocular  symptoms  observed  are  lacrimation,"^  photo- 
phobia, colored  vision  and  spectra.  There  is  a  sense  of  pressure,  with  the 
occasional  occurrence  of  edema  of  the  upper  eyelid  and  exophthalmos.  The 
smus  outlet  may  become  obstructed,  by  edema,  in  which  case  the  escape  of 
the  secretions  by  way  of  the  nose  is  prevented  and  accumulation  takes  place. 
In  the  majority  of  cases  the  onset  is  sudden  and  the  course  of  the  disease  brief; 
it  usually  terminates  in  the  first  week  in  evacuation,  \\ith  subsidence  of  the 
symptoms.  In  a  certain  proportion  of  cases  the  disease  "becomes  chronic. 
Periostitis  of  the  walls  of  the  sinus,  particulariy  of  the  orbital  wall,  may  occur. 
Ulceration  and  necrosis  of  the  bony  wall  ensue  with  resulting  infection  of  the 
orbit,  or  the  latter  may  occur  Anthout  previous  organic  changein  the  bony  wall. 
Intracranial  lesions  may  follow  eariy  in  the  case  and  occur  in  the  same  manner,  in 
both  instances  the  infection  taking  place  from  thrombophlebitis  of  the  veins 
which  traverse  the  walls  of  the  sinus.     Intracranial  infection  may  be  followed 


516  THE  SURGERY  OF  THE  HEAD 

by  extradural  and  intradural  abscesses,  meningitis,  encephalitis  and  cerebral 
abscess,  thrombosis  of  the  superior  longitudinal  sinus,  etc. 

Chronic  frontal  sinusitis,  as  a  rule,  is  a  sequel  of  the  acute  affection. 
It  may,  ho^ve^'er,  be  due  to  an  extension  of  an  ozena  or  to  traumatism.  The 
frequency  with  which  chronic  sinusitis  follows  the  acute  disease  is  due  to  the 
fact  that  the  anterior  ethmoid  cells  are  usually  invoh'ed;  with  the  subsidence 
of  the  acute  inflammation  of  the  sinus  the  ethmoiditis  frequently  remains  as  a 
source  of  infection.  One  frontal  sinus  may  infect  its  fellow  with  or  without 
perforation  of  the  septum.  Chronic  frontal  sinusitis  may  terminate  in  dilata- 
tion of  the  sinus  or  destruction  of  its  bony  Avails  and  abscess.  The  symi)toms 
may  continue  as  in  the  acute  stage  (headache  and  reflex  ocular  disturbances) 
or  they  may  subside  altogether.  Dilatation  may  develop  in  a  short  time  or  it 
may  occupy  years.  The  sinus  may  attain  the  size  of  a  pigeon's  egg  or  it  may 
have  a  capacity  of  several  ounces.  The  orbital  wall  usually  yields  first,  though 
the  entire  bony  capsule  may  suffer,  molecular  absorption  of  bone  taking  place 
in  both  instances.  Distention  of  the  sinus  may  also  occur  through  accumula- 
tion of  mucus  (mucocele)  or  mucopurulent  material.  In  about  75  per  cent  of 
the  cases  of  mucocele  the  outlet  of  the  sinus  is  closed. 

Termination  by  ulceration  of  the  lining  membrane  of  the  sinus,  followed 
by  caries  or  necrosis  of  the  sinus  wall  and  abscess,  is  nearly  twice  as  common 
as  the  dilating  variety.  The  manifestations  of  the  disease  may  not  occur  for  a 
long  time  (after  the  first  year  in  one-sixth  of  100  cases,  K  i  1 11  a  n),  the  infection 
following  a  persistent  anterior  ethmoiditis.  Sequestra  form  in  cases  of  necrosis. 
The  orbital  wall  is  affected  in  about  two-thirds  of  the  cases,  the  cranial  wall 
and  the  frontal  wall  being  affected  about  equally  in  the  remaining  cases. 

As  in  acute  sinusitis,  a  considerable  percentage  of  cases  of  infection  of 
the  orbit  and  encephalon  occur  without  demonstrable  lesion  of  the  bony  wall. 
Cerebral  abscess  is  the  most  commonly  produced  lesion  in  these  cases. 

The  symptoms  of  the  destructive  and  purulent  fonn  of  chronic  sinusitis 
vary  greatly.  Pyorrhea  nasalis  may  be  abundant  and  fetid.  Pain  is  often 
a  prominent  feature.  Orbital  abscess  may  occur.  Swelling  of  the  lids  and 
displacements  of  the  globe  produce  diplopia.  Fistulous  openings  may  follow 
spontaneous  rupture.  Optic  neuritis  may  occur  as  a  complication.  The 
symptoms  of  intracranial  infection  closely  resemble  those  which  follow  dis- 
eases of  the  middle  ear. 

In  the  diagnosis  of  suspected  chronic  dilating  sinusitis  (the  "latent  sinu- 
sitis" of  some  authors)  cocainization  of  the  middle  turbinate  and  the  use  of  a 
nasal  specuhim  with  blades  adapted  to  the  examination  of  the  middle  meatus 
will  be  of  service.  As  a  routine  procedure,  however,  the  general  surgeon  will 
resect  the  middle  turbinate  and  pursue  the  investigation  with  either  the  probe 
or  the  cannula.  The  dangers  arising  from  the  use  of  the  probe  must  be  borne 
in  mind ;  at  least  two  fatal  cases  are  on  record  due  to  perforation  of  the  cranial 
floor  by  the  instrument.  As  soon  as  the  bent  end  of  the  instrument  is  an 
inch  above  the  anterior  process  of  the  middle  turbinate  it  should  be  within 
the  sinus  (Fig.  297).  The  Rdntgen  rays  may  be  of  service  in  localization  of 
the  probe.  A  sudden  gush  of  pus  may  follow  the  introduction  of  the  probe 
into  the  outlet  of  the  sinus.  This  may  be  due  to  the  evacuation  of  an  empyema 
of  the  sinus,  or  there  may  be  anomalies  of  the  ethmoid  cells,  the  pus  coming 
from  an  anterior  ethmoiditis.     These  two  affections  frequently  coexist.     If 


THE    FRONTAL    SIXUSES 


517 


pus  does  not  follow  the  introduction  of  the  probe,  a  fine  cannula  should  be 
substituted  and  air  forced  in  with  the  view  of  forcing  out  the  pus.  Tender- 
ness is  also  an  important  diagnostic  symptom,  and  when  this  is  conjoined 
with  orbital  cellulitis,  the  diagnosis  is  placed  beyond  a  doubt.  Chronic  em- 
pyema of  the  frontal  sinns  may  lurk  beneath  the  clinical  picture  of  trigeminal 
neuralgia.  A  further  diagnostic  sign  is  a  crackling  sound  produced  on  pres- 
sure, due  to  attenuation  of  the  sinus  walls.  If  exploration  with  the  probe 
fails,  the  surgeon  should  make  an  exploratory-  puncture  from  without  rather 
than  assume  the  risks  of  a  puncture  from  the  direction  of  the  nasal  cavity. 
The  operation  may  be  both  exploratory-  and  curative.  Simple  dilatation 
is  recognized  by  the  local  deformity  and  displacement  of  the  e^e,  the  usual 
absence  of  pain,  the  slow  progress  of  the  case,  and  the  parchmentlike  crack- 
ling on  palpation.  Ulceration  is  announced  by  circumscribed  periostitis, 
abscess,  perforation,  fistula,  or  caries.  Cerebral  complications  'nill  give  rise 
to  characteristic  symptoms.  In  exploratory^  operations  it  should  be  remem- 
bered that  cerebral  complications  occur  \^ithout  perforation  of  the  sinus  waU. 
In  doubtful  cases  it  will  therefore  be 
necessary-  to  expose  the  dura,  and  even 
to  incise  this  if  it  shows  evidence  of  in- 
fection, and  to  explore  the  cortex. 

Treatment. — Acute  frontal  sinusitis 
requires,  as  a  rule,  only  expectant  treat- 
ment, such  as  rest  in  bed.  diaphoresis, 
warm  applications  to  the  brow,  inhala- 
tion of  hot  steam,  politzerization  and 
cocainization  of  the  nose,  and  the  ad- 
ministration of  such  remedies  as  phe- 
nacetin,  salol.  etc.  If  relief  is  not  ob- 
tained, the  middle  turbinate  should  be 
resected  and  the  sinus  irrigated  with 
warm  saline  solution.  If  the  symptoms 
still  persist  and  the  encephalon  is  threat- 
ened, the  sinus  should  be  laid  open  from 
without.     It  may  be  necessary  to  enter 

the  cranial  cavity  through  the  frontal  wall  to  gain  access  to  an  abscess  of  the 
frontal  lobe  and  effect  its  drainage. 

In  chronic  frontal  sinusitis  it  has  been  recommended  to  resect  the  middle 
turbinate  as  a  routine  procedure  (Hajek).  This  operation  of  turbin- 
ectomy  is  tantamount  to  a  radically  curative  operation  prior  to  the  occur- 
rence of  destructive  lesions.  Xotliing  is  to  be  gamed  by  it  after  suppurative 
compHcations  have  occurred.  It  is  performed  \\"ith  the  cold  snare;  one-third 
of  the  bone  is  removed.  For  the  first  one  or  two  weeks  after  its  performance 
an  increased  amount  of  secretion  occurs,  after  which  time  mucus  alone  is 
discharged,  which  discharge  finally  ceases  after  a  month  or  two.  The  method 
has  only  a  limited  range  of  apphcation.  and  that  in  the  hands  of  the  expert 
rhinologist.     It  is  inadequate  to  meet  the  indications  in  severe  cases. 

The  operation  of  choice  consists  of  an  exploratory  opening  of  the  sinus, 
followed  by  simple  irrigation  if  the  bone  is  healthy  and  the  mucosa  free  from 
polypoid   hypertrophies.     The   irrigation   is   repeated   daily    (K  u  h  n  t) .     In 


Fig.    297. — Sagittal   Section"   theough  the 

Froxtal  Sixrs. 

Showing  the  probe  passed  into  the  sinus  from 

the  middle  meatus  (after  Lichtwitz). 


518 


THE    SURGERY    OF    THE    HEAD 


suitable  cases  extirpation  of  the  mucosa  is  the  preferable  operation  (K  o  c  h  e  r). 
This  may  be  accomplished  after  entire  removal  of  the  anterior  ^^■all  through  verti- 
cal and  horizontal  incisions  (N  e  b  i  n  g  e  r,  P  r  a  u  n) ;  or  after  removal  of  the 
orbital  wall  (J  a  n  s  e  n) ;  or  by  opening  the  sinus  through  the  frontal  wall, 
temporary  resection  of  the  corresponding  nasal  bone  with  the  breaking  up  of  the 
infundibular  cells  to  insure  a  permanent  communication  and  free  drainage  by 
way  of  the  nasal  fossa  (K  i  1 1  i  a  n).  A  narrow  briclge  at  the  orbital  margin 
is  preserved  to  prevent  disfigurement  (Fig.  298) .  This  form  of  intervention  also 
gives- access  to  the  ethmoid  labyrinth.  In  operations  on  the  frontal  sinus  from 
without  the  posterior  nares  should  be  plugged,  the  incision  made  through  the 
eyebrow,  an  exploratory  puncture  made  through  the  incision,  and  the  sinus 
entered  by  either  removal  of  the  walls  or  a  temporary  osteoplastic  resection  of 
the  same.     Resection  of  the  nasal  bone  and  division  of  the  nasal  process  of  the 

superior  maxillary  bone  are  accomplished 
through  a  prolongation  of  the  original  inci- 
sion. A  chisel  is  used  in  the  last  step  men- 
tioned, and  a  small  portion  of  the  frontal 
bone  is  likewise  divided.  Diseased  ethmoid 
cells  are  removed  with  bone  forceps  and  the 
curet  and  a  communication  established  be- 
tween the  sinus  and  the  nose.  A'o  irriga- 
tion is  permissible  until  two  or  three  weeks 
have  elapsed  (W  inkle  r) . 

Foreign  Bodies. — In  the  majority  of 
cases  foreign  bodies  in  the  frontal  sinuses 
have  consisted  of  projectiles,  chiefly  from 
old-fashioned  firearms.  These  may  heal  in 
the  sinus  and  remain  indefinitely,  but,  as  a 
rule,  a  fistula  results.  Sinusitis  is  invaria- 
bly set  up.  Metallic  foreign  bodies  are  easil}' 
discoverable  at  the  present  day  by  the  use 
of  the  Rontgen  rays.  There  are  a  number 
of  ancient  cases  recorded  in  which  animate 
foreign  bodies  have  gained  access  to  the 
sinus,  mature  insects  or  larvae  having 
reached  there  through  the  nasal  cavities. 
Tumors  of  the  Frontal  Sinuses.— Of  the  benign  growths  of  the  frontal 
sinuses  osteoma  is  the  most  important.  Polypi  and  cysts  are  regarded  as 
essential  features  of  chronic  inflammation.  Even  osteomas  are  held  by  some 
to  be  of  inflammatory  origin.  They  may  be  attached  to  the  bone  by  a  broad 
base  or  pedicle  or  embedded  in  the  mucous  membrane,  or  they  may  lie  loose  in 
the  cavity  of  the  sinus.  They  are  essentially  confined  to  the  period  of  child- 
hood and  adolescence.  The  nucleus  and  pedicle  are  cancellous.  They  may 
attain  the  size  of  an  orange,  separating  the  walls  of  the  sinus  and  encroaching 
on  the  cranial  cavity  and  the  orbit.  The  functional  disturbance  is  slight  in  this 
slow  gro^Adng  tumor,  though  exceptionally  ocular  disturbances,  compression, 
etc.,  are  produced.  They  may  be  complicated  with  sinusitis;  they  may 
simulate  dilating  sinusitis,  so  that  an  exploratory  puncture  may  be  necessaiy 
for  the  differentiation. 


Fig.  298. — Frontal  Sinus,  the  Ante- 
rior AND  Inferior  Walls  of  which 
have  been  removed,  with  the 
Exception  of  a  Narrow  Bridge 
Corresponding  to  the  Orbital 
Margin. 

O.  B.,  Orbital  bridge  (after  Killian). 


THE    JAWS  519 

The  treatment  of  osteoma  is  ininiediate  extirpation  under  the  most  careful 

asepsis. 

Of  malignant  growths  orighiating  in  the  frontal  sinus,  sarcoma  is  alone 
to  be  considered.  In  the  recorded  cases  the  disease  advanced  rapidly  and 
invad(>d  the  contiii-uous  cavities  early.  Carcinoma  has  never  been  kno'\\Ti  to 
originate  in  the  frontal  sinus  and  c\-en  seconcUa-y  invasion  is  of  extremely  rare 
occurrence. 

THE  JAWS 

Fractures  of  the  Superior  Maxillary  Bone.^These  arise  principally 
through  direct  violence,  as,  for  instance,  a  blow  from  a  bludgeon  or  a  stone, 
a  kick  from  a  vicious  horse,  suicidally  ■ffiflicted  gunshot  injuries  from  the  direc- 
tion of  the  cavity  of  the  mouth,  etc.  Fractures  of  the  alveolar  processes 
were  formerly  quite  common,  arising  from  the  use  of  the  old-fashioned  lever  or 
"kev"  used  in  tooth  extraction.  Occasionally  complete  separation  of  both 
upper  jaws  from  their  surroundings  and  attachments  has  been  observed. 
Fracture  of  the  body  of  the  jaw,  beyond  a  simple  fissure  in  the  wall  of  the 
antnnn,  is  somewhat  rare;  the  processes,  as  a  mle,  receive  the  force  of  the  blow. 
Transverse  fracture  of  both  bodies  of  the  upper  jaw  may  be  produced,  never- 
theless, by  a  blow  received  on  the  face  just  below  the  nasal  bones,  and  a  vertical 
fracture,  running  through  the  median  suture  of  the  palate  and  separating  the 
two  superior  maxillas,  may  result  from  a  blow  on  the  chin. 

These  fractures  are  not  dangerous  in  themselves,  but  complicating  con- 
ditions that  threaten  life  ma}-  occur.  The  first  in  importance  of  these  is 
hemorrhage  from  the  internal  maxillary  artery.  This  is  most  likely  to 
occur  in  gunshot  injuries.  The  next  most  important  compHcation  is  injury 
of  the  infraorbital  nerve,  producing  paralysis  in  the  distribution  of  the  nerve. 
Intractable  neuralgia  may  likewise  follow  transverse  and  oblicjue  fracture 
from  final  involvement  of  the  nervc-tnmk  in  the  callus.  Suppurative 
inflammation  of  the  antrum  may  also  occur  in  comphcated  and  compound 
comminuted  fractures. 

In  the  treatment  of  fractures  of  the  alveolar  processes  but  little  difificulty 
is  experienced  in  replacing  the  fragments,  since  these  are  usually  displaced  in 
the  direction  of  the  oral  cavity.  They  become  easily  displaced  again,  however, 
from  the  movements  of  the  tongue,  and  measures  must  be  taken  to  retain  them 
in  position.  This  is  best  accomplished  by  wiring  the  teeth  of  the  fractured 
portion  to  adjoining  teeth  that  are  firmly  fixed.  On  no  accomit  should  the 
fragments  be  removed  without  a  thorough  trial  of  conservative  measures, 
including  the  interdental  splint  (see  page  522). 

Fractures  of  the  body  of  the  bone  reciuire  no  treatment  of  themselves, 
yet  the  comphcations  may  be  of  sufficient  gravity  to  demand  interference. 
This  is  specially  true  of  injury  of  the  internal  maxillary  artery.  Ligation  of 
the  conmion  carotid  artery  is  useless,  owing  to  the  free  anastomosis  of  the 
internal  maxillary  with  vessels  supplied  by  the  vertebral  arteries.  Partial 
or  temporary  resection  of  the  upper  jaw  will  gi^-e  access  to  the  bleeding 
point,  and  permit  the  application  of  the  ligature,  thermocautery,  or  tampons. 
Paralysis  folloT\'ing  nerve  injury  may  disappear  without  treatment.  In  in- 
tractable neuralgia  from  pressure  of  callus  t1ie  removal  of  the  latter  by  chisel 


520  THE  SURGERY  OF  THE  HEAD 

and  mallet  is  indicated  (for  the  Treatment  of  Suppurative  Inflammation 
of  the  Antrum,  see  page  529). 

Luxation  of  the  Malar  Bone. — This  can  occur  only  from  the  aiDpli- 
cation  of  great  force.  The  bone  ma}'  be  loosened  from  all  its  connections 
with  the  upper  jaw  and  frontal  and  temporal  bones.  Replacement  and  re- 
tention of  the  displaced  bone  in  position  are  accomplished  without  difficulty. 

Fractures  of  the  Inferior  Maxilla.— Fractures  of  the  lower  jaw,  like 
those  of  the  upper  jaw,  may  involve  the  alveolar  processes  or  the  body  of 
the  bone.  The  remarks  already  made  in  connection  ^\■ith  the  fracture  of  the 
alveolar  processes  of  the  upper  jaw  will  apply  to  those  of  the  lower  jaw  as  well. 

In  fracture  of  the  body  of  the  lower  jaw  the  line  may  pass  transversely  so 
as  to  separate  the  whole  of  the  ascending  ramus.  Fracture  of  the  condyle, 
as  well  as  of  the  coronoid  process,  may  also  occur.  Owing  to  the  pro- 
tection afforded  by  the  parotid  gland  and  masseter  muscle,  fracture  of  this 
portion  by  direct  force  is  rare.  Fracture  by  indirect  force,  the  latter  being 
transferred  through  the  mandibular  arch,  is  likewise  rare,  the  latter  structure, 
being  less  resistant  than  the  ramus,  giving  way  first.  Fracture  of  the  coronoid 
has  been  observed  as  the  result  of  muscular  action.  This  fracture  unites  only 
by  fibrous  tissue,  the  strong  vascular  tendon  of  the  temporal  muscle,  which 
does  not  produce  bony  callus,  replacing  the  periosteum  at  this  point.  It  is 
diagnosed  by  palpation  with  the  finger  in  the  mouth.  Pain  will  be  felt  on 
pressure  and  displacement  of  the  process  will  be  observed. 

Transverse  or  oblique  fractures  result  either  from  direct  force,  as  gun- 
shot wounds  or  blows  from  a  horse's  shoe,  or  from  indirect  force,  as  compres- 
sion by  falls  on  the  chin  or  simultaneous  pressure  at  both  angles  of  the  jaw. 
They  occur  at  the  weakest  portion  of  the  bone,  i.  e.,  in  the  region  of  the 
bicuspid  or  first  molar  tooth.  Both  artery  and  nerve  are  torn;  hemorrhage, 
however,  is  rare,  but  there  is  usually  loss  of  sensibility  in  the  front  teeth  and 
the  skin  covering  the  chin.  The  displacement  of  the  fragments  is  peculiar. 
The  fracture  occurs  at  one  side  of  the  median  line,  a  shorter  fragment  corre- 
sponding to  the  injured  side,  and  a  longer  fragment  corresponding  to  the  un- 
injured side.  The  muscles  which  close  the  jaw  (temporal,  masseter,  pterygoid) 
are  attached  to  the  former,  while  to  the  latter  are  attached  those  which  open 
the  jaw  (mylohyoid,  geniohyoid).  The  shorter  fragment  is  dra^ATi  upward, 
approximating  the  attached  teeth,  while  the  longer  fragment  is  dra\\Ti  dowTi- 
ward,  separating  the  teeth  attached  to  it  from  those  of  the  upper  jaw.  In 
addition,  the  shorter  fragment  is  drawn  toAvard  the  median  line  by  the  action 
of  the  pterygoids. 

Occasionally  the  bone  gives  way  in  two  places,  the  central  portion  being 
dragged  doA^^lward  by  the  mylohyoid  muscles.  In  addition  to  the  typic 
displacement,  splintered  fragments  may  be  displaced  in  various  directions. 

The  disturbances  of  function  are  marked.  Mastication  is  impossible, 
the  mouth  remains  partly  open,  the  saliva  dribbling.  Speech  is  diflficult,  owing 
to  inability  to  form  the  labial  and  sibilant  sounds.  Swallowing  is  also  A^ery 
much  embarrassed. 

The  fracture  is  usually  complicated  "with  a  wound  of  the  mucous  mem- 
brane and  sometimes  with  a  wound  of  the  external  soft  parts  as  well.  Infec- 
tion from  the  mouth  is  common  and  septic  bronchitis  and  septic  pneumonia 
may  occur  from  the  passing  of  the  inspired  air  over  the  putrid  Avound  secretions. 


TIIK    JAWS 


521 


The  diagnosis  does  not  prosont  marked  difficulty  unless  there  is  very 
great  obliquit>'  of  the  lino  of  fracture,  in  which  case  the  mobility  of  the 
fragments  can   he  demonstrated  only   by  grasping  the  bone  with  both  hands. 

Treatment  of  Fracture  of  the 
Lower  Jaw. — The  mouth  is  to  l)e 
irrigated  frec^uently  with  a  boric  acid 
solution  or  permanganate  of  potash, 
and  in  the  intervals  a  pledget  of 
cotton  saturatetl  with  a  3  to  5  per 
cent  solution  of  chlorid  of  zinc  should 
be  kept  applied  to  the  wound  in  the 
mucous  membrane.  The  food  must 
be  liquid  and  always  followed  by 
irrigation  and  renewal  of  the  chlorid 
of  zinc  pledget.  Feeding  is  best  car- 
ried on  by  means  of  a  rubber  tube 
and  funnel.  If  there  is  a  complicat- 
ing external  wound,  a  drainage-tube 
maj^  be  inserted,  or  if  necessary  an 
opening  may  be  made  for  that  pur- 
pose. 

If  the  fragments  can  be  held  in 
place  by  simple  approximation  of  the 
lower  to  the  upper  teeth,  measures  to 
maintain  this  approximation  are  in- 
dicated. A  Barton  bandage  or  one 
of  its  modifications  is  usually  em- 
ployed (Fig.  195).  In  order  to  secure  direct  upward  pressure  on  the  mandible 
the  following  device  is  useful :  A  strip  of  tin  5  inches  wide  in  front  tapering  to 
3  inches  posteriorly,  with  the  anterior  end  bent  upward  to  form  a  projecting 

shelf,  is  fitted  to  the  head,  to 
which  it  is  secured  by  a  circular 
plaster-of-Paris  bandage.  The 
anterior  curved  end  projects  from 
the  forehead  and  strips  of  adhe- 
sive plaster  pass  from  the  shelf 
do^Miward  and  backward  beneath 
the  jaw,  exerting  traction  up- 
ward and  forward,  this  o^'ercom- 
ing  the  posterior  displacement 
(K  n  a  p  p) .  Or  the  head  may 
be  encased  in  a  plaster-of-Paris 
cap  in  which  two  projecting  iron 
arms  are  incorporated,  the  latter 
serving  as  points  of  support  for 
the  strips  of  adhesive  plaster 
that  pass  beneath  the  mancHble  (Fig.  299). 

The  Interdental  Splint. — When  this  method  of  treatment  can  be  made 
available,  it  is  by  far  the  best  method  for  fractures  of  the  mandible.     The 


Fig.  299. — Apparatus   for  the    Treatment   of 
Fracture  of  the  Lower  Jaw. 


Fig.  300. — The  Articulator. 


522 


THE   SURGERY    OF   THE    HEAD 


patient's  mouth  and  teeth  are  carefully  cleaned  beforehand.  It  may  be  neces- 
sary to  administer  a  general  anesthetic.  An  impression  is  taken  as  for  upper 
and  lower  dentures,  no  attempt  being  made  to  reduce  the  fragments.  The 
method  of  procedure  is  as  follows:  The  ordinary  modeling  cups  of  the  dentist 
are  filled  with  yellow  beeswax;  the  latter  is  gradually  heated  over  an  alcohol 
flame  and  worked  with  the  fingers  until  it  is  soft.     Impressions  of  the  upper  and 


^^^^^^^K' 

r  'Vf-v,.^  ^^^^1 

^^^^^' 

^^^  ^--y^^i  ■ 

I   ^^^^^^^^^1 

Hr^ 

^^m 

^K^^^^ 

^^^^^^^^^^^^^^^^^^H 

^HH 

Fig.  301. — Plaster-of-Paris   Models   of  Upper  and  Lower  Teeth  Molded  in  the  Articulator. 
A,  Cast  of  fracture  of  the  lower  jaw;   B,  the  same  after  the  site  of  the  fracture  has  been  sawed  across  and 
the  normal  relations  of  the  parts  restored. 


the  lower  teeth  are  taken  and  the  wax  allowed  to  harden.  A  plaster-of -Paris 
cast  of  the  upper  jaw  is  then  made  and  this  is  secured  by  means  of  plaster  cream 
to  the  upper  arm  of  an  articulator  (Fig.  300).  In  the  same  way  a  cast  of  the 
lower  jaw  is  made,  the  site  of  the  fracture  recognized  and  marked,  and  the  cast 
sawed  in  two  at  that  point  in  a  line  corresponding  as  nearly  as  possible  with 
the  fracture. 

The  two  pieces  of  the  cast  of  the  lower  jaw  are  now  brought  into  their  proper 

relation  so  that  the  lower  and  upper  teeth 
articulate  normally;  they  are  then  fast- 
ened together  by  means  of  plaster  cream 
on  the  lower  arm  of  the  articulator  (Fig. 
301).  On  this  model  of  the  reduced  frac- 
ture an  interdental  splint  of  vulcanite 
(Fig.  302)  is  made  by  a  mechanical  den- 
tist. The  splint  is  trimmed  so  as  not  to 
impinge  on  the  gums.  In  placing  the 
splint  in  position  it  is  first  adjusted  to 
the  upper  teeth;  the  teeth  of  the  lower 
jaw  are  now  forced  into  the  recesses  made 
for  them  on  the  corrected  model,  the  displacement  thus  being  rectified. 
Suitable  bandages  (Barton's  or  a  modification  thereof)  are  apphed  so 
as  to  hold  the  lower  jaw  firmly  in  place  against  the  splint.  The  latter  is  worn 
for  from  thirty  to  fifty  days. 

The  interdental  splint  is  suitable  for  the  treatment  of  fractures  through  the 
dental  arch.     Various  slight  modifications  of  its  form  may  be  rendered  necessary 


Fig.  302. — Interdental  Splint  of  Vul- 
canite. 


THE    JAWS 


523 


for  feeding  purposes  so  as  to  take  advantage  of  any  gaps  in  the  teeth  that  may 
exist. 

In  fractures  in  the  region  of  the  molar  teeth  special  care  must  be  exercised 
not  to  separate  the  jaws  any  wider  than  is  absolutely  necessary  in  the  applica- 
tion of  the  splint,  lest  failure  of  the  front  teeth  to  articulate  when  the  healing 
is  completed  result.  Here  the  portion  of  the  splint  interposed  between  the 
teeth  should  be  as  thin  as  is  consistent  with  strength,  for  it  is  e^'ident  that  the 
greater  the  separation  of  the  jaws,  the  greater  will  be  the  stress  on  the  posterior 
fragment.  The  thin  gold  splint  of  Ottolengui  (Fig.  303)  answers  the 
purpose  best  under  these  circumstances. 

If  the  fracture  is  in  front  of  the  bicuspid  teeth,  a  short  splint  or  a  simple 
capping  of   the    lower  teeth   in 
cases    where    there   is  little   de- 
formity  will   fulfil    all    require- 
ments. 

In  cases  of  double  fracture 
an  interdental  splint  is  indis- 
pensable; if  one  break  is  at  or 
near  the  angle,  the  splint  should 
be  as  thin  as  possible  so  as  to 
avoid  increasing  the  deformity 
at  this  point. 

Roberts's  Method. — A  den 
tal  splint  is  made,  as  in  the 
method  last  described.  This  is 
held  in  position  by  one  or  two 
loops  of  silver  wire,  the  ends  of 
which  are  passed  through  the 
soft  parts  close  to  the  anterior 
and  posterior  surfaces  of  the 
body  of  the  jaw,  by  means  of  a 
needle,  and  secured  externally 
by  being  twisted  over  a  roll  of 
gauze  covered  by  rubber  tissue, 
or  a  piece  of  heavy  rubber  tubing. 

Necrosis  of  splintered  fragments  may  require  subsequent  removal 
union  previously  obtained  is  not  generally  disturbed  by  such  removal. 

Matas's  Adjustable  Metallic  Interdental  Splint. — This  apparatus  is 
designed  with  the  object  of  immobilizing  the  broken  fragments  of  the  jaw 
without  restricting  its  movements  as  a  \vhole,  so  that  it  permits  the  mouth  to 
be  opened  and  closed  at  will.  It  is  specially  adapted  for  compound  fractures 
of  the  symphysis  and  body  of  the  jaw.     It  consists  of  the  following  parts: 

1.  A  detachable  dental  plate  or  mouth-piece,  made  of  block  tin  (Fig.  304). 
This  is  hollowed  to  fit  loosely  over  the  crowns  of  the  teeth.  Its  edges  form 
two  flanges  which  project  downward,  the  one  on  the  outer  or  buccal  side  ex- 
tending to  the  neck  of  the  teeth,  while  the  one  on  the  inner  or  lingual  side 
is  longer  and  almost  touches  the  gums  when  applied.  Two  partial  sections 
of  the  splint  are  made  approximately  on  a  level  with  the  bicuspids;  they 
include  the  width  of  the  splint  to  its  outer  rim.     These  sections  are  for  the  pur- 


FiG.    303.- 


GoLD    Interdental    Splint    (.after    Otto- 
lengui). 

For  use  in  cases  of  fracture  posterior  to  the  last 
molar.  A,  The  splint;  B,  the  splint  shown  in  place  on 
the  plaster  model. 


The 


524 


THE    SURGERY    OF    THE    HEAD 


pose  of  increasing  the  inflexibility  of  the  splint,  thus  facilitating  its  adaptation 
to  different  forms  of  the  lower  dental  arch.  The  hollow  groove  or  gutter  in 
the  splint  can  be  filled  with  dental  wax;  this  serves  to  hold  loose  teeth  in 
place,  to  reduce  the  mobility  of  the  splint  to  a  minimum,  and  to  overcome 
the  difficulty  of  ()]:>taining  a  uniform  compression  caused  by  the  vertical  irregu- 
larities of  the  teeth.     The  splint  is  made  in  three  sizes. 


Fig.  304. — Matas's  Adjustable  Splint  for  Fracture  of  the  Lower  Jaw. 

A,  Upper  ^^ew;   B,  lower  view,   showing  partial  sections  cut  in  the  soft  block-tin  mouth-piece  to  facilitate 

adaptation  to  different  forms  of  the  lower  dental  arch  (after  Matas). 


2.  An  adjustable  chin-piece  made  of  perforated  aluminum,  shaped  to  fit 
the  contour  of  the  lower  jaw,  and  secured  to  the  lower  arm  of  the  clamp 
by  a  thumb-screAv  (Fig.  305).  In  order  to  prevent  injurious  pressure  on 
the  skin,  the  chin-piece  is  padded  with  cotton  wadding  or  felt  covered 
with  gauze  smeared  with  oxid  of  zinc  ointment. 

3.  A  clamp  which  holds  the 
mouth-piece  and  chin-piece  to- 
gether. This  consists  of  an  upper 
and  lower  arm  connected  to- 
gether by  a  joint,  and  capable  of 
adju.stment  by  means  of  a  screw 
attached  by  a  swivel  joint  to 
the  uj)per  arm  (Fig.  305).  The 
pressure  required  to  hold  the  in- 
terdental splint  and  chin-piece 
firmly  in  position  when  applied 
is  obtained  by  this  screw. 

Where  extensive  comminution 
is  present,  the  block-tin  inter- 
dental splint  may  be  used  with- 
out the  clamp  and  chin-piece,  the 
latter  being  substituted  by  a 
molded  chin  splint  made  of  coarse  flannel  thoroughly  soaked  in  plaster  cream, 
and  held  in  place  by  a  plaster-of -Paris  or  a  starch  bandage. 

After  reducing  the  fracture  and  restoring  the  contour  of  the  dental  arch, 
preferably  under  an  anesthetic,  the  splint  is  fitted  to  the  arch  of  the  teeth  by 
molding  Avith  the  fingers.     If  the  dental  wax  is  used,  this  is  softened  in  hot 


Fig.  .305. — Matas's  Adjustable  Splint  for  Fracture 
OF  the  Lower  Jaw. 
1,  Block-tin  interdental  splint;  2,  clamp  adjusted 
and  tightened  with  a  screw ;  3,  chin  plate  of  aluminimi, 
which  can  be  moved  backward  and  forward  and  secured 
by  the  screw  4  (after  Matas). 


THE   JAWS 


525 


water  and  spread  over  the  gutter  surface  of  the  splint;  the  sphnt  is  then 
apphed  and  held  in  place  until  the  dental  wax  cools.     The  clamp  is  attached 


Fig.  306. — Matas's  Adjustable  Splint  for  Fracture  of  the  Lower  Jaw. 
Shown  on  the  adult  skull.     A,  Front  view;    B,  lateral  view  (after  Matas). 

to  the  splint  after  the  latter  has  been  adjusted  to  the  jaw,  by  means  of  a 
hook  at  the  tip  of  the  clamp,  which  fits  in  a  groove  or  slot  in  the  center  of 
the   inner  surface  of   the  splint. 

If  great  swelling  takes  place, 
or  necrosis  of  the  skin  of  the  chin 
is  threatened,  the  pressure  of  the 
screw  must  be  relaxed  from  time 
to  time.  Freciuent  irrigation  of 
the  mouth  must  be  practised. 

Dislocations  of  the  Lower 
Jaw. — A  meniscus  separates  the 
two  articular  surfaces  of  the 
temporomaxillar}^  articulation, 
constituting  what  is  called  a 
"double  joint."  The  opening 
and  closing  of  the  mouth,  the 
forward  and  backward  move- 
ments of  the  jaw,  as  well  as 
those  made  in  grinding,  and 
marked  by  a  simultaneous  back- 
ward movement  of  one  condyle 
and  a  forward  movement  of  the 
other,  are  performed  through  the 
medium  of  this  interarticular 
cartilaginous  plate. 

In  spite  of  its  apparent  great 
freedom    of    motion    dislocation 

occurs  in  but  one  direction,  namely,  forward  (Fig.  308),  and  then  usually  by 
forcible  efforts  at  opening  the  mouth  (gaping) .     During  this  act  the  condyle, 


Fig. 


307. — Matas's   Adjustable    Splint   for    Frac- 
ture of  the  Lower  Jaw. 
The  splint  is  adjusted  in  position.     The  apparatus 
is  held  in  place  by  a  Gibson  or  Barton  bandage  (after 
Matas) . 


526 


THE    SURGERY    OF   THE    HEAD 


with  the  meniscus,  is  forced  on  the  articiihir  eminence,  and,  in  case  tlie  poste- 
rior wall  of  the  capsule  gix-es  way,  the  condyle  with  the  meniscus  is  carried  in 
front  of  the  articular  eminence,  from  which  position  tiie  masseter  is  unable  to 
extricate  it  by  attempts  at  closing  the  mouth.  Lax  conditions  of  the  capsule, 
either  congenital  or  acquired  through  nutritive  disturbances,  predispose  to  the 
accident.  In  such  cases  clicking  sensations  referred  to  the  joint  and  due  to 
abnormal  movements  of  the  meniscus  (a  form  of  subluxation)  occur. 

External  force,  such  as  a  blow  on  the  teeth  when  the  mouth  is  wide  open, 
may  give  rise  to  the  dislocation. 

Habitual  Dislocation. — After  a  dislocation  has  once  taken  place,  the 
condition  may  occur  from  slight  causes.  This  is  due  to  the  formation  of  a 
broad  cicatrix  during  the  process  of  healing  of  the  torn  capsule. 


1 

1 

■ 

2 

in^^Jl 

^ 

^^^B 

J, M 

»   ' 

f  - 

/^^tf^H 

i^wF 

^  1^ 

i^^ti 

^/^KK 

^ 

1 

^V^' 

-^ 

^^^^«f-'' .   '■ 

^ 

^ 

Fig.  308. — Dislocation  of  the  Mandible. 
Method  of  reduction  by  a  pry  made  of  a  piece  of  splint  material  covered  with  a  bandage. 


Dislocation  of  the  jaw  is  very  rare  in  children.  This  is  due  to  the  fact 
that  the  articular  eminence  is  absent,  and  hence  there  is  no  obstruction  to 
the  sliding  movements  of  the  meniscus  when  this  is  thrown  forward  as  the 
mouth  is  widely  opened. 

S3maptoms. — The  open  mouth,  dribbling  saliva,  and  projecting  front  teeth 
form  a  characteristic  clinical  picture.  With  the  index-finger  introduced  into 
the  external  meatus  auditorius  the  normal  depression  felt  when  the  mouth  is 
opened  is  found  to  be  greatly  exaggerated.  The  prominence  of  the  coronoid 
process  is  carried  anteriorly  and  is  felt  below  the  middle  of  the  zygomatic  arch. 

Treatment. — Reduction  is  accomplished  by  pushing  both  coronoid  proc- 
esses below  the  articular  eminence.     The  thumbs  of  both  hands  are  placed 


THE    JAWS  527 

with  the  palmar  surfaces  downward  on  the  lower  molars  of  each  side,  the  points 
of  the  fingers  resting  on  the  lower  edge  of  the  bod}-  of  the  jaw,  and  the  two  little 
fingers  meeting  beneath  the  point  of  the  chin.  The  back  molars  are  pressed 
downward,  and  at  the  same  time  the  point  of  the  chin  is  elevated  by  the  two 
little  fingers.  Or,  a  pry  may  be  improvised  from  a  common  desk  ruler,  or  piece 
of  splint  material  covered  with  bandage  muslhi  (Fig.  308).  In  some  cases  it 
may  be  necessar}-  to  make  pressure  on  the  coronoid  process  from  within  the 
mouth.  In  old  cases  Stromeyer's  forceps,  constructed  so  as  to  grasp  the 
lower  molars  and  the  chin,  afford  a  longer  leverage  for  the  manipulation.  In 
cases  otherwise  irreducible,  open  incision  and  removal  of  the  obstruction  to 
reduction,  or  resection,  may  be  performed.  Unilateral  dislocations  of  the 
lower  jaw  are  ver}'  rare.  They  are  reduced  without  difficulty  by  the  manipu- 
lations already  described. 

In  an  intractal^Ie  case  of  habitual  dislocation  of  the  lower  jaw  I  succeeded  in 
correcting  the  tendency  to  recurrence  by  the  following  operation:  The  parts 
were  exposed  through  an  incision,  the  temporomandibular  articulation  opened 
at  the  site  of  the  external  lateral  ligament,  a  portion  of  the  latter  removed  so  as 
to  shorten  the  ligament,  and  the  eminentia  articularis  chiseled  aw^ay.  The 
external  lateral  ligament  was  then  sutured  and  the  external  wound  closed. 

Inflammation  of  the  Gums. — Subperiosteal  or  alveolar  abscess,  the 
result  of  caries  of  the  teeth,  may  advance  from  the  alveolus  and  find  its  way 
beneath  the  gum.  These  suppurative  processes  should  ])e  o]^cned  early  and 
treated  by  an  antiseptic  mouth-wash.  Metastatic  (pyemic)  abscesses  may 
result  from  their  presence.  Their  recurrence,  or  the  persistence  of  a  fistulous 
opening,  usually  requires  the  removal  of  the  offendmg  tooth.  If  this  is 
neglected,  the  pus  may  finally  burrow  beneath  the  periosteum  and  other 
fistulous  openings  form;  or,  the  pus  may  continue  to  burrow,  reaching  the 
region  of  the  angle  of  the  jaw,  or  that  of  the  symphysis  menti  in  the  inferior 
maxilla,  or  the  infraorbital  region  in  the  superior  maxilla,  pointing  externally. 

This  development  of  suppurative  periostitis  of  the  jaw  is  accompanied 
by  swelling  of  the  soft  parts,  pain,  and  occasionally  high  fever.  Multiple 
pyemia  may  develop  as  a  consequence,  or  life  may  be  threatened,  in  the  case  of 
the  upper  jaw,  by  an  extension  of  inflammation  along  the  nerves  to  the  base  of 
the  skull.  Usually,  however,  the  affection  pursues  a  favorable  course.  Free 
incision  and  antiseptic  treatment  promptly  relieve  the  symptoms,  but  a  fistula 
leading  to  the  carious  root  of  a  tooth  or  to  a  necrosis  of  the  alveolar  process  is 
left.  The  tooth  must  be  extracted  and  all  diseased  portions  scraped  away. 
In  more  extensive  necrosis  of  the  jaw  sequestrotomy  is  necessar}',  the  fistulous 
opening  being  utilized  for  a  portion  of  the  incision  for  this  purpose,  if  it  is  found 
impracticable  to  remove  the  sequestrum  from  the  inside  of  the  mouth 
(intrabuccal  sequestrotomy),  a  procedure  always  desirable,  on  account  of  the 
cosmetic  effect.  This  will  be  facilitated  by  waiting  until  the  sequestra  have 
become  loosened,  free  drainage  and  antiseptic  treatment  being  employed  in 
the  meanwhile. 

The  cutting  of  a  wisdom  tooth  in  adults  may  be  so  painful  as  to  recpire  an 
incision  at  the  hands  of  the  surgeon. 

Gingivitis. — This  is  an  affection  in  which  the  edge  of  the  gum  surrounding 
the  tooth  is  inflamed  and  sometimes  ulcerated.  It  originates  from  septic 
inflammation  arising  from  decomposition  of  food.     It  appears  as  an  epidemic 


528  THE  SURGERY  OF  THE  HEAD 

affection,  occasionally  several  children  in  the  same  family  being  attacTced, 
The  affection  readily  yields  with  the  use  of  an  antiseptic  mouth-wash,  such  as 
permanganate  of  potash  or  chlorate  of  potash.  Cleansing  the  ulcerated  edges 
with  absorbent  cotton  dipped  in  a  2.5  per  cent  solution  of  carbolic  acid  is  useful, 
in  conjunction  with  the  above.  The  affection  should  not  be  confounded  with 
scurvy. 

Lead  Poisoning. — This  gives  rise  to  a  peculiar  grayish-blue  discoloration 
of  the  gums.  I'lcerative  destruction  of  the  gums  is  observed  as  a  result  of 
mercurial  stomatitis.  Deposits  of  tartar  may  also  give  rise  to  inflammation 
and  ulceration  of  the  gums. 

Necrosis  of  the  Maxillary  Bones. — In  addition  to  necrosis  resulting 
from  suppurative  periodontitis  already  mentioned,  which  gives  rise  more 
commonly  to  small  sequestra,  the  two  following  diseases,  though  rare,  con- 
stitute much  more  serious  affections. 

Phosphorus  Necrosis, — Employees  of  match  factories,  prior  to  the  en- 
forcement of  certain  hygienic  rules,  suffered  from  this  disease.  The  etiology 
of  the  affection  is  obscure.  It  appears  to  be  due  to  the  exposure  of  carious 
teeth  to  the  fumes  of  the  phosphorus,  though  a  bacteriologic  origin  has  been 
suggested,  the  phosphorus  in  some  unknown  manner  favoring  the  development 
of  the  fungi.  The  sequestra  separate  very  slowly,  and  new  bone  forming  over 
the  diseased  osseous  structure,  if  exposed  to  the  phosphorus  fumes,  in  its  turn 
becomes  diseased.  The  processes  are  exceedingly  putrid;  septic  bronchitis 
and  pnetmionia  may  supervene,  or  even  general  infection  ensue. 

Early  antiseptic  treatment  is  imperative.  Necrosed  portions  of  bone 
are  to  be  removed.  This  more  frequently  involves  a  resection  of  the  entire 
bone  than  a  sequestrotomy.  If  the  periosteum  is  preserved  or  an  in- 
volucrum  of  healthy  bone  has  formed,  reproduction  of  the  entire  bone  may 
take  place. 

Acute  Infectious  Osteomyelitis. — This  occurs  exclusively  in  the 
lower  jaw,  as  it  alone  possesses  a  medullary  cavity.  It  is  an  exceedingly 
dangerous  affection,  though  of  slow  development.  It  may  follow  the  exan- 
themata of  children.  The  treatment  consists  in  early  and  free  incisions. 
Edema  of  the  glottis  and  subsequent  suffocation  may  occur  after  inflammation 
of  the  soft  parts.  Intrabuccal  sequestrotomy  should  be  performed,  whenever 
practicable,  to  avoid  extensive  cicatrices  on  the  face.  If  external  incisions 
cannot  be  avoided  these  should  l^e  placed  along  the  line  of  the  jaw. 

Necrotic  Caries. — This  attacks  by  preference  the  superior  maxillary 
bone  at  the  infraorbital  ridge,  and  the  malar  bone.  It  is  usually  of  tubercu- 
lous origin.  The  treatment  consists  in  the  vigorous  application  of  the  sharp 
spoon  or  the  removal  of  small  secjuestra.  An  ugly  depressed  scar  results; 
this  may  lead  eventually  to  ectropion,  and  require  the  operation  of  blepharo- 
plasty  (see  page  495). 

Inflammation  of  the  Antrum  of  Highmore. — Inflammation  of  the 
antrum,  or  maxillary  sinus,  occurs  either  from  extension  of  catarrhal  rhinitis 
through  the  lower  nasal  duct,  from  frontal  sinusitis,  ethmoiditis,  various  nasal 
obstructions,  such  as  nasal  polypi  damming  up  the  secretions  in  the  middle 
meatus  (C  r  y  e  r)  and  enlarged  middle  turbinates,  from  extension  of 
inflammation  from  periodontitis,  particularly  of  the  posterior  molars,  or  from 
suppurative  periostitis  of  the  walls  of  the  superior  maxillary  bone.     The  dis- 


THE    JAWS  529 

f^ase  occurs  only  in  adult  life;  the  antrum  is  not  developed  in  childhood.*  The 
right  side  is  affected  in  75  per  cent  of  the  cases.  Five  cases  out  of  140  were 
bilateral  (C  line). 

Hydrops  of  the  Antrum.— This  arises  from  a  serous  inflammation 
of  the  lining  of  the  antrum;  this  latter  is  the  most  common  of  the  affections 
of  this  cavity.  The  opening  conununicating  between  the  antrum  and  the 
nasal  duct  is  small  and  easily  closed  b}-  a  slight  inflammator}-  swelling, 
an  accumulation  of  the  products  of  inflammation  resulting.  The  portion  of 
the  maxillary  \\-all  corresponding  to  the  canine  fossa  becomes  bulging,  and 
even  the  entire  half  of  the  face  may  become  unduly  prominent.  The  con- 
dition may  simulate  malignant  disease  of  the  superior  maxillary  bone.  In 
the  latter,  however,  the  tumor  develops  through  the  palate  and  nasal  fossa, 
while  in  the  former  these  structures  are  the  least  affected.  In  malicrnant  dis- 
ease the  bony  wall  of  the  canine  fossa  is  converted  into  a  softmass;  in 
hydrops  this  usually  becomes  thinned  so  that  palpation  discloses  the  so-called 
parchment  crepitation.  If  the  bone  preserves  the  normal  consistency  or 
becomes  thickened  by  inflammatory  irritation,  this  crepitation  niav  be  absent. 
Other  causes  of  hydrops  of  the  antrum  are  said  to  be  abnormal  growths 
of  a  wisdom  tooth  (McCoy),  polypi  and  mucous  cysts,  or  cystic 
degeneration  of  the  mucous  membrane    (A  d  a  m  s  ,    W  e  r  n  b  e  r). 

Suppurative  inflammation  may  develop  from  a  simple  hydrops  or  from 
suppurative  inflammation  of  the  adjacent  molars.  The  occurrence  of  suppura- 
tion is  marked  by  pain,  fever,  and  edematous  swelling  of  the  cheek.  The 
disease  may  terminate  in  perforation  of  the  bony  ^vall  of  the  antrum,  particu- 
larly at  the  inner  portion  of  the  infraorbital  ridge,  or  the  periosteum  of  the 
antrum  may  become  attacked  and  necrosis  result. 

Treatment.— Acute  cases  of  simple  serous  inflammation  of  the  antrum 
usually  subside  \Althout  operation.  Operative  measures  are  demanded,  how- 
ever, both  in  chronic  serous  inflammation  and  in  suppurative  inflammation. 
If  crepitation  is  present,  an  incision  may  be  made  at  the  thinnest  part  as  an 
emergency  measure.  This  can  almost  alw^ays  be  accomplished  from  within 
the  mouth  by  passing  the  blade  of  a  stout  knife  from  the  direction  of  the  gums. 
If  a  carious  tooth  or  the  roots  of  a  tooth  are  present,  the  extraction  of  these  will 
usually  open  the  way  into  the  antrum.  If  not,  a  hole  may  be  driUed  into  the 
cavity  from  the  bottom  of  the  tooth  socket  and  the  contents  evacuated. 

For  the  radical  cure  of  suppurative  inflammation  of  the  antrum  the  fol- 
lowing operation  best  fulfils  the  indications:  The  nasal  passages  are  first 
thoroughl}-  cleared  of  polypi,  turbinate  hypertrophies,  and  other  causes  of 
obstruction.  A  curved  incision  is  made  at  the  site  of  the  root  of  the  corre- 
sponding bicuspid  tooth  in  such  a  manner  as  to  reflect  a  flap  from  the  gin- 
givolabial  fold  of  mucous  membrane  and  expose  the  anterior  wall  of  the 
antrum  at  this  point.  The  latter  is  then  perforated  and  access  gained  to  its 
cavity.  The  opening  is  enlarged  sufliciently  to  permit  the  introduction 
of  a  curet,  and  the  entire  cavity  is  thoroughly  curetted.  The  nasal  cavity 
is  then  entered  on  a  level  with  the  lowest  point  of  the  antral  cavity  by  per- 

*  Rudaux  ("Ann.  d.  mal.  de  I'oreille  et  du  lanTix,"  Sept.,  1S95)  reports  the  case  of  an 
intant  three  weeks  old,  in  whom  empyema  of  the  antrum   was  due  to   the  presence  of  a 
prematurely  developed  tooth  in  the  floor  of  that  cavity.     The  presence  of  the  latter  at 
tins  early  age,  it  is  presumed,  was  likewise  the  result  of  a  premature  development. 
35 


530 


THE    SURGERY    OF    THE    HEAD 


forating  the  inner  bony  wall  from  the  direction  of  the  latter.  This  opening 
should  be  enlarged  by  the  removal  of  sufficient  bone  to  allow  for  subsequent 
contraction. 

The  mucous  membrane  flap  at  the  site  of  the  original  opening  is  sutured 
in  place.  The  subsequent  treatment  consists  in  frequent  antiseptic  irrigation 
from  the  direction  of  the  nasal  cavity.  This  is  to  be  continued  until  the  puru- 
lent discharge  into  the  nasal  cavity  ceases.  The  free  communication  between 
the  latter  and  the  cavity  of  the  antrum  insures  against  a  relapse. 

Malignant  growths  of  the  antrum  of  Highmore  occur,  both  as 
sarcomas  and  as  carcinomas.  Neuralgic  pains  referred  to  the  teeth  at  the  com- 
mencement lead  to  the  extraction  of  the  latter.  Symptoms  of  inflammation 
of  the  antnnn  appear,  with  mucopurulent  discharge  from  the  nose.  Swell- 
ing of  the  soft  parts  of  the  superior  maxillary  region  occurs,  with  reddening 
and  soft  edema.  Implication  of  the  skin  of  the  cheek  finally  takes  place.  The 
globe  is  displaced  by  the  crowding  upward  of  the  orbital  plate  (see  Fig.  309), 

with  resulting  exophthalmos.  Occlusion  of 
the  tear  duct  leads  to  overflow  of  tears  on  the 
cheek  (epiphora).  The  anterior  wall  becomes 
thinned  from  expansion  of  the  walls  of  the 
cavity.  The  nasal  fossa  is  encroached  upon 
and  respiration  thereby  obstructed.  In  some 
cases  the  alveolar  border  is  depressed.  Ulcer- 
ation of  the  part  projecting  into  the  nasal 
fossa  gives  rise  to  frequently  recurring  hemor- 
rhage. Finally,  the  growth  makes  its  way 
through  the  posterior  wall  and  invades  the 
zygomatic  and  sphenomaxillary  fossa,  thence 
passing  into  the  temporal  fossa;  or  it  may 
pass  through  the  sphenomaxillar}-  fissure  to 
the  orbit,  or  through  the  sphenoidal  fissure  or 
the  foramen  rotundum  into  the  middle  fossa 
of  the  cranium. 

The  mucoperiosteum  of  the  antrum  is  a 
common  situation  for  periosteal  sarcomas.  The  disease  is  most  frequently 
observed  in  youth  and  before  middle  life.  Sarcoma  as  it  springs  from  a  tooth 
follicle  is  confined  exclusively  to  children.  The  germ  of  the  first  permanent 
molar  is  a  favorite  situation  for  these  growths. 

Primary  epithelioma  as  it  affects  the  antrum  is  a  rare  and  insidious  dis- 
ease occurring  in  patients  past  middle  life.  It  commences  with  pain  in  the 
upper  jaw,  followed  by  a  fullness  of  the  parts,  edema  of  the  lids,  and  braA^Tii- 
ness  of  the  skin  of  the  cheek ;  the  latter  finally  breaks  do^^'n  into  an  ulcer.  The 
growth  extends  into  the  orbit  and  along  the  pter\-goid  muscles.  The  lymph- 
atic glands  of  the  neck  are  invoh'ed  late  in  the  disease.  Metastases  to 
internal  organs  are  rare. 

The  treatment  demands  complete  resection  of  the  upper  jaw  (see  page  537). 

Contracture  of  the  Lower  Jaw ;    Lockjaw. — This  is  freciuently  due 

to  inflammatoiy  conditions  in  the  neighborhood  of  the  mandibular  arch  and 

the  lower  portion  of  the  ascending  ramus.     Lockjaw  of  arthritic    origin    is 

extremeh'  rare. 


Fig.  309. — Sarcoma  of  the  Antrum. 


THE    JAWS  531 

The  inflammatory  conditions  giving  rise  to  acute  lockjaw  are  (1) 
periostitis:  (2)  paradenitis  following  inflammation  of  the  lymphatic  glands 
in  the  submental  and  submaxillary  region,  and  of  the  submaxillar}-  sahvary 
gland;  (3)  parotitis;  (4)  aggravated  forms  of  acute  tonsillitis  with  involvement 
of  the  peritonsillar  connective  tissue;  (5)  osteitis  of  the  lower  jaw  from  any 
cause:  the  immobility  of  the  jaw  ceases,  however.  -^Ith  the  subsidence  of  the 
inflammation  in  the  majority  of  cases. 

The  cicatricial  form  of  lockjaw  constitutes  a  more  frequently  observed 
and  most  intractable  form  of  contracture.  This  results  from  the  presence  of 
solid  cordlike  bands  of  cicatricial  tissue  following  destructive  ulcerative  changes 
(noma)  which  have  their  origin,  as  a  rule,  on  the  buccal  mucous  membrane. 
The  acute  inflammatoiy  suppurative  conditions  above  alluded  to  may.  though 
rarelv.  result  in  the  formation  of  cicatricial  tissue  and  give  rise  to  cicatricial 
lockjaw. 

Bony  fusion  i  synostosis  i  of  the  temporomandibular  articulation  has 
been  observed,  though,  as  before  stated,  the  arthritic  form  of  contractm-e  in  tliis 
joint  is  rare.  This  articulation,  however,  is  not  exempt  from  the  diseases  which 
attack  other  articulations.  Disease  of  the  coronoid  process  may  also  give 
rise  to  lockia^v. 

Treatment  of  Lockjaw. — This  -^111  var\-  T\ith  the  origin  of  the  condition. 
The  preventive  treatment  consists  in  placing  a  cork  between  the  teeth,  fu'.st 
locating  it  between  the  incisors,  then  between  the  canine  teeth,  and  finally 
between  the  molars.  In  the  beginning  of  contracture  of  inflammatory'  origin, 
including  that  due  to  the  development  of  cicatricial  tissue,  this  method  may  be 
tried. 

The  operative  treatment  consists  first  in  attempting  to  separate  the  jaw 
by  means  of  wooden  wedges,  the  patient  being  placed  under  an  anesthetic. 
This  failing,  intrabuccal  or  subcutaneous  division  of  cicatricial  bands  may  be 
tried.  Usually,  however,  it  will  be  better  to  dissect  away  the  cicatricial 
tissue  and  supply  its  place  by  an  attached  skin  flap  from  the  cheek,  passed 
through  a  slit  in  the  cheek.  The  base  of  the  flap  is  subsequently  separated 
and  the  slit  closed. 

The  formation  of  an  artificial  joint  in  front  of  the  point  of  cicatricial  or 
bony  contracture  (E  s  m  a  r  c  h  .  "W  i  1  m  s)  is  a  procedure  which  may  be 
resorted  to  with  advantage.  About  hah  an  inch  of  the  bone  is  removed  and 
mobihty  established  through  subsequent  passive  movements.  This  is  preferable 
to  Rizzoli's  operation  of  simply  sa-^ing  through  the  mandibular  arch,  for  the 
reason  that  the  latter  operation  is  freciuently  followed  by  reunion  of  the  frag- 
ments. 

In  convulsive  or  spasmodic  lockjaw  operative  treatment  is  of  no  avail. 
The  older  operations  of  myotomy  and  tenotomy  for  this  condition  should  be 
abandoned. 

Resection  of  the  condyle  is  indicated  m  contractures  originating  in  disease 
of  the  temporomaxiUari-  articiflation.  Diflicidty  is  usually  experienced  in 
remo^-ing  the  head  of  the  bone  from  the  glenoid  fossa.  In  cases  of  disease  of  the 
coronoid  process  the  latter  may  become  welded  to  the  upper  jaw  by  bony 
proliferation:  this  may  be  di^'ided  by  the  chisel  and  maUet  or  narrow  saw. 

Benign  Tumors. — The  maxillar\'  bones,  from  their  pecvihar  formation, 
the  processes  of  dentition,  the  presence  of  the  antrum,  and  irritations  arising  in 
the  oral  ca-\-ity.  are  specially  disposed  to  tumor  formation. 


532  thf:  surgery  of  the  head 

Subperiosteal  abscesses,  "when  not  opened,  give  rise  to  a  separation  of  the 
periosteum,  the  latter  forming  a  new  bony  layer.  The  symptoms  of  crepita- 
tion may  be  present,  or  the  tumor  may  assume  a  solid  consistency.  This 
constitutes  the  so-called  subperiosteal  cyst  of  the  alveolar  process. 
The  pus  which  originally  filled  the  cyst  changes  to  a  clear  m\icous  fluid, 
Avhich,  from  the  presence  of  crystals  of  cholesterin,  sometimes  looks  like  butter. 
These  cysts  sometimes  attain  the  size  of  a  hazelnut  and  empty  their  contents 
into  the  antrum.  Extraction  of  the  roots  of  carious  teeth  is  usually  sufficient 
for  a  cure.     If  not,  the  bony  wall  of  the  cyst  must  be  incised. 

Fibromas. — These  are  of  rare  occurrence.  They  develop  at  or  about  the 
twentieth  year  of  life  in  strong  and  healthy  individuals  and  sometimes  attain 
the  size  of  a  walnut.  Their  favorite  location  is  the  alveolar  processes  of  the 
canine  teeth.  Thej^  are  generall}'  of  osteal  origin,  though  they  uislj  spring  from 
the  periosteum.  They  are  usually  of  almost  bom'  hardness.  The}^  are  best 
treated  by  resection  of  the  alveolar  process  from  which  they  spring.  Recur- 
rence after  complete  removal  is  not  observed. 

Odontomas. — These  are  ]3eculiar  growths  which  appear  in  young  in- 
dividuals. They  consist  of  cystic  formations  surrounded  by  bony  walls,  arising 
from  either  tooth  germs  or  the  teeth.  The  cysts  contain  either  a  number  of 
teeth,  or  one  giant  tooth,  the  result  of  the  fusion  of  the  germs  of  several  teeth, 
or  fibromatous  or  chondromatous  masses  may  inclose  displaced  tooth  germs. 
Their  usual  location  is  the  neighborhood  of  the  last  molar.  The  treatment  is 
by  extirpation. 

Osteomas  of  the  Maxillary  Bones. — These  sometimes  attain  a  very  large 
size.  They  are  exceedingly  benign,  becoming  troublesome  only  by  their  per- 
sistent but  slow  growth,  and  the  great  deformity  which  they  produce.  The 
globe  may  be  displaced  forT\'ard,  and  cerebral  disturbances  may  follow  their  in- 
vasion of  the  base  of  the  skull.  Visual  disturbances  are  not  observed  as  a  result 
of  stretching  of  the  optic  nerve,  from  the  fact  that  this  takes  place  very  slowly. 

Adenomas  and  chondromas  of  the  maxillar}-  bones  occupy  a  midway 
ground  between  benign  and  malignant  growths.  They  are  much  rarer  in 
their  occurrence  than  sarcomas  and  carcinomas. 

Malignant  Tumors. — These  consist  of  sarcomas  and  carcinomas.  Of 
these,  the  former  are  the  more  frequently  obser^-ed. 

The  superior  maxilla  is  not  infrequently  the  seat  of  periosteal  sarcoma. 
It  often  arises  from  the  mucoperiosteal  structure  of  the  gums,  though  the  most 
common  situation  is  the  antrum,  in  which  case  it  causes  considerable  enlarge- 
ment of  the  body  of  the  bone,  encroaching  upon  the  nasal  fossae  and  the  orbit, 
displacing  the  globe;  and  occasionally  depressing  the  alveolar  border.  It  may 
perforate  the  posterior  wall  of  the  antnun  and  enter  the  sphenomaxillary, 
zygomatic,  or  temporal  fossa.  It  may  enter  the  orbit  from  the  direction  of 
the  sphenomaxillary  fissure,  or,  finally,  reach  the  cavity  of  the  cranium  through 
the  foramen  rotundum  or  the  sphenoidal  fissure.  It  ma}-  perforate  the  antnim 
at  its  anterior  wall  and  involve  the  soft  parts  of  the  face.  Projections  into  the 
nasal  fossa  are  liable  to  ulcerate  and  giA'e  rise  to  sanious  discharge  and  hem- 
orrhage. Sarcomas  involving  the  germ  of  the  first  permanent  molar  may  occur 
in  childhood.  The  disease  is  rare  in  infancy,  however,  occurring  most  fre- 
quently after  the  fifteenth  year.  As  a  rule,  the  sarcoma  is  of  exceedingly 
rapid  groAvth. 


THE    JAWS  533 

The  nuicoiis  membrane  of  the  soft  and  hard  palate  may  be  the  seat  of 
sarcomas,  which  may  be  mistaken  for  adenomas  or  endothehomas.  Melanotic 
sarcoma  in  this  region  is  very  rarely  seen. 

Sarcoma  of  the  Alveolar  Process;  Epulis. — This  originates  from  the 
external  periosteum  of  the  alveolar  process.  Epulis  is  characterized  by  a 
peculiar  color,  a  mixture  of  blue,  red,  and  brown.  This  is  due  to  a  brown 
pigmentation.  Epulis  is  the  only  instance  of  pigmented  sarcoma  that  is  not 
exceedingly  malignant.  Microscopically  the  tumor  is  characterized  by  a  very 
great  number  of  giant-cells.  Some  specimens  of  the  growth  consist  exclusively 
of  giant-cells. 

Epulis  resembles,  except  in  color,  the  ordinary  fibroma  of  the  gums.  While 
the  latter,  however,  may  be  removed  by  a  simple  incision  involving  only  the 
gums,  the  former  requires,  in  order  to  prevent  recurrence,  removal  of  a  portion 
of  the  alveolus  as  w^ell.  If  permitted  to  extend,  the  disease  spreads  in  all 
directions  and  may  finally  require  for  its  cure  partial  or  complete  resection  of 
the  upper  or  the  lower  jaw. 

Sarcomas  of  the  body  of  the  jaw  are  of  far  greater  malignity  than  the 
foregoing.  They  are  observed  usually  between  the  fortieth  and  the  fiftieth  year 
of  life.  The  disease  appears  most  commonly  in  the  body  of  the  upper  jaw  as 
soft  tumors  of  rapid  growth.  Microscopically  they  consist  of  small  round  cells 
in  a  scanty  stroma.  The  antrum,  orbital  and  nasal  cavities  are  speedily  invaded, 
and  finally  the  ethmoid  and  base  of  the  skull  become  involved  in  the  disease. 
As  they  extend  outwardly  the  skin  of  the  facial  region  becomes  involved,  break- 
ing down  into  ulceration. 

The  lower  jaw  may  be  attacked  by  sarcoma,  where  the  latter  may  attain 
large  proportions.  It  is  less  frequently  observed  here  than  in  the  superior 
maxilla,  however.  When  it  springs  from  the  outer  surface  of  the  ramus  it  may 
be  mistaken  for  a  tumor  of  the  parotid.  The  growth  extends  somewhat 
symmetrically.  Cystic  sarcoma  also  is  found  in  this  locality.  Lymphatic 
glandular  involvement  is  rare,  and  occurs  at  a  late  period  and  from  septic 
processes,  if  at  all. 

Sarcoma  of  the  jaw  is  liable  to  recur,  even  after  the  most  careful  resection  of 
the  bone.  Exceptionally,  in  the  case  of  the  lower  jaw,  removal  of  the  bone 
from  the  temporomaxillary  articulation  to  the  symphysis  menti  is  followed  by 
cure. 

Carcinomas  attack  the  alveolar  processes  of  both  jaws,  particularly  the 
lower.  They  may  occur  primarily  from  the  gums,  or  secondarily  from  the 
adjacent  soft  parts.  They  are  essentially  a  disease  of  advanced  life.  They 
tend  to  break  down  rapidly  into  ulceration,  the  teeth  are  loosened  early  and 
drop  out,  and  the  entire  growth  soon  assumes  the  appearances  of  a  foul  ulcera- 
tion W'ith  hard  edges.  The  lymphatic  glands  at  the  angle  of  the  jaw  become 
involved  early  in  the  disease. 

The  only  disease  wdth  which  carcinoma  is  at  all  likely  to  be  confounded  is 
epulis.  The  latter,  however,  does  not  ulcerate  early  unless  from  being  acci- 
dentally bitten.     Lymphatic  involvement  is  not  the  rule  in  epulis. 

The  body  of  the  upper  and  lower  jaw  is  rarely  attacked  by  primary  car- 
cinomas. ^Malignant  growths  in  this  location  belong,  probabh'  with  rare 
exceptions,  to  the  small-celled  sarcomas.  The  absolute  differential  diagnosis 
depends  on  microscopic  examination. 


534 


THE    SURGERY   OF   THE    HEAD 


Patients  with  malignant  disease  of  the  jaw  usually  fall  first  into  the  hands 
of  the  dentist,  and  the  disease  is  sometimes  far  advanced  when  it  comes 
under  the  observation  of  the  surgeon.  Comparatively  few  cases  are  operated  on 
early,  and  even  these  show  marked  tendency  to  rapid  recurrence.  Only  the 
immunity,  which  rare  and  isolated  cases  enjoy,  from  a  return  of  the  disease 
justifies  the  surgeon  in  yielding  to  the  importunate  demands  of  the  patient 
for  operative  interference. 


RESECTION  OF  THE  LOWER  AND  UPPER  JAWS 

This  may  be  partial  or  total.  In  the  former,  removal  of  the  processes 
or  portions  of  the  body  of  the  bone  is  accomplished.  In  total  resection  all  of 
the  lower  jaw,  or  half  of  the  upper  jaw,  with  its  attached  palate  and  malar  bone, 
is  removed.     The  inferior  maxillary  bone  is  seldom  entirely  removed. 

Performance  of  the  operation  with  the  patient  only  half  anesthetized,  in 
order  to  prevent  the  blood  from  finding  its  way  into  the  air-passages  and  produc- 
ing suffocation,  has  been  recommended.     Preliminary  tracheotomy  with  the 


Fig.  310. — Rose's  Dependent  Head  Position. 


use  of  the  tampon  cannula  (T  r  e  n  d  e  1  e  n  b  u  r  g)  (Fig.  311)  or  a  folded 
napkin  crowded  into  the  pharynx  and  occluding  the  glottic  opening  (N  u  s  s  - 
b  a  u  m)  has  also  been  employed  for  the  same  purpose.  Nasal  intubation  and 
the  tamponing  of  the  pharynx  (C  r  i  1  e  ,  see  page  304),  or  the  slow  raising  of 
the  patient  to  the  sitting  position  after  anesthetization  (French),  is 
preferable  to  either  of  these.  Rose's  dependent  head  position  may 
also    be    employed  with  advantage  (Fig.  310). 

Resection  of  the  Alveolar  Processes. — Benign  growths  situated 
anteriorly,  and  even  epulis,  may  be  removed  through  the  mouth  without 
external  incision.  The  operation  is  commenced  by  the  removal  of  the  teeth 
corresponding  to  the  alveolar  processes  to  be  resected.  L  i  s  t  o  n  '  s  forceps 
(Fig.  90,  B)  in  the  case  of  the  lower  jaw,  and  the  chisel  and  mallet  in  the  case  of 
the  upper  jaw,  are  to  be  employed  in  making  the  necessary  rectangular  in- 
cisions. These  incisions  limit  the  part  to  be  removed  at  each  extremity  of  the 
growth.  The  portion  between  the  rectangular  incisions  is  freely  separated 
from  the  lip  and  removed  by  means  of  the  cross-cutting  forceps  (Fig.  312).     In 


Til  10  JAWS  535 

carcinoma  or  sarcoma  a  free  removal  must  be  practised.  In  the  case  of  the 
lower  jaw  it  is  best  to  remove  the  (Mitire  thickness  of  the  body  of  the  bone  for 
a  considerable  distance  beyond  lli(>  limits  of  the  disease. 

Resection  of  Half  the  Lower  Jaw.— 1die  corresponding  median  incisor 
is  extracted.  The  incision  should,  as  far  as  possible,  be  placed  below  the 
bonier  of  the  bone  so  that  the  resulting  scar  may  be  hidden.  The  lower 
lip  is  divided  in  the  median  line  and  the  incision  is  carried  downward  to  a 


Fig.  311. — Trendelenburg  Cannula  with  Attachment  for  Administering  Chloroform. 

point  below  the  level  of  the  symphysis  menti.  The  incision  is  then  carried 
along  just  below  the  lower  border  of  the  bone  as  far  as  the  angle,  and  then 
upward  behind  the  posterior  border  of  the  ascending  ramus  to  within  |  of  an 
inch  of  the  lobe  of  the  external  ear  (Fig.  313).  The  facial  artery  is  divided 
and  both  ends  at  once  secured.  The  incision  terminates  below  the  edge  of 
the  parotid  gland,  and  the  most  important  branches  of  the  facial  nerve  are 
preserved.     The  tissues  of  the  face  and  the  masseter  muscle  are  dissected 


Fig.  312. — Cross-cutting  Forceps. 

away  from  the  bone  or  tumor,  and  the  jaw  sawed  through  at  the  symphysis 
with  either  a  small  frame  saw  or  the  G  i  g  1  i  wire  saw.  The  tissues  forming 
the  floor  of  the  mouth  are  divided  by  carrying  the  knife  along  the  inner  sur- 
face of  the  bone,  care  being  taken  to  preserve  the  sublingual  gland.  The 
bone  is  now  grasped  by  the  lion  forceps  (Fig.  161)  and  the  internal  pterygoid 
muscle  brought  into  view;  the  latter  must  now  be  detached.  The  jaw  is  now 
forced  downward,  the  soft  tissues  held  out  of  the  way  by  means  of  retractors, 


536 


THE    SURGERY   OF   THE    HEAD 


when  the  coronoid  process  is  brought  forward.  The  temporal  muscle,  which 
completely  surrounds  the  latter,  is  now  separated  from  the  bone.  It  is  some- 
times extremely  difficult  to  do  this,  owing  to  the  unusual  length  of  the  process, 
or  the  fact  that  it  is  crowded  against  the  malar  bone  by  the  bulk  of  the  tumor. 
Under  these  circumstances  it  may  be  necessary  to  cut  off  the  coronoid  with 
bone  forceps.  After  clearing  the  coronoid  the  jaw  is  still  further  depressed 
from  before  backward  in  order  to  throw  the  condyle  forward ;  the  parotid  gland 
and  masseter  are  held  out  of  the  way  by  means  of  retractors.  As  the  coro- 
noid becomes  prominent  the  joint  capsule,  together  with  the  ligaments  and 
insertion  of  the  external  pterygoid  muscle,  alone  remains  to  be  divided.  The 
first  named  may  be  divided  by  the  knife,  but  the  others  are  torn  through  in 
crowding  the  bone  out  of  the  glenoid  cavity  by  forcibly  depressing  it.     The 

muscular  fibers  are  not  to  be 
divided  with  the  knife,  though 
the  inferior  dental  nerve  may  re- 
quire section,  in  order  to  prevent 
it  from  being  dragged  out  of  its 
bony  canal.  In  executing  the 
movement  which  depresses  the 
jaw  and  forces  the  condyle  for- 
ward, care  should  be  taken  not 
to  rotate  the  jaw  outward,  else 
the  internal  maxillary  artery  will 
be  torn  or  divided  and  give 
rise  to  troublesome  or  even 
severe  hemorrhage.  If  rotation  is 
avoided,  the  periosteum  usually 
separates  from  the  bone  and 
both  it  and  the  artery  are  left 
behind  intact. 

All  hemorrhage  is  to  be  ar- 
rested, and  the  oral  cavity  iso- 
lated from  the  remainder  of  the 
wound  by  a  row  of  sutures  unit- 
ing the  edge  of  the  mucous  mem- 
brane of  the  cheek  with  that  of 
the  floor  of  the  mouth.  A  row 
of  external  sutures  is  now  applied,  between  which  small  openings  for  drain- 
age are  to  be  left.  A  drainage-tube  is  to  be  placed  in  the  lower  angle  of  the 
wound;  this  passes  into  the  mouth  and  drains  the  oral  cavity.  Antiseptic 
dressings  apphed  externally  and  frequent  irrigation  of  the  mouth  constitute 
the  after-treatment. 

This  procedure  may  be  modified  or  varied  on  account  of  the  growth  of  the 
neoplasm  at  the  central  portion  of  the  inferior  maxillary  arch.  Resection 
of  the  bone  at  this  point  involves  the  separation  of  the  geniohyoglossus  muscle 
of  each  side,  which  will  permit  the  root  of  the  tongue  to  fall  backward  and 
suffocation  to  occur.  This  is  to  be  prevented  by  passing  a  silk  Hgature  through 
the  tongue.  This  part  of  the  operation  is  given  in  charge  of  an  assistant,  and 
the  tongue  fastened  by  a  strip  of  adhesive  plaster  to  the  cheek  for  the  first  few 


Fig.    313. — External    Incision    for    Resection    of 
Half  of  Lower  Jaw. 


THE    JAWS 


537 


days  afterward.  The  head  of  the  patient  is  held  bent  slightly  forward  as  he 
lies  on  his  side  during  the  after-treatment,  and  on  the  first  sign  of  suffocation 
the  tongue  is  drawn  forward. 

Some  discomfort  arises  from  the  failure  of  the  teeth  to  approximate  nor- 
mally in  mastication.  In  time  this  will  be  partially  obviated  by  growth  of 
new  bone.  A  skilful  dentist  may  be  able  to  construct  a  frame  of  gold  or  silver 
wire  for  the  purpose  of  maintaining  proper  separation  of  the  remaining  por- 
tions of  the  jaw,  in  order  that  the  teeth  may  articulate  properly  wdth  each 
other. 

Removal  of  the  entire  lower  jaw  may  be  necessary  in  phosphorus 
necrosis.  Under  these  circumstances  the  operation  should  be  performed 
both  sul)periosteally  and  intrabuccally.  In  young  subjects  reproduction  of 
the  entire  lower  jaw  may  occur. 
If  some  months  are  permitted  to 
elapse  between  the  removal  of 
the  two  halves  (or  the  removal 
of  the  two  jaws,  as  it  is  some- 
times called),  the  periosteum 
becomes  thickened  and  serves 
as  a  support  for  the  portion  last 
operated  on. 

Resection  of  the  temporo= 
maxillary  articulation  is  rarely 
required  except  for  ankylosis  of 
the  jaw  arising  from  inflamma- 
tory conditions  in  the  neighbor- 
hood, or  irreducible  dislocation 
of  the  lower  jaw.  The  head  of 
the  bone  is  exposed  by  an  inci- 
sion extending  from  the  anterior 
margin  of  the  zygomatic  arch 
downward  and  H  inches  in  front 
of  the  auricle.  The  soft  parts 
are  crowded  away  from  the  neck 
of  the  bone,  the  latter  divided 
with  the  chisel  and  mallet,  and 
the  head  of  the  bone  removed. 

The  proximity  of  the  internal  maxillary  artery  prohibits  the  use  of  the  saw  or 
bone-cutting  forceps.  A  movable  articulation  is  to  be  secured  by  early,  per- 
sistent, and  methodic  movements  of  the  jaw. 

Resection  of  the  Upper  Jaw. — This  is  indicated  in  cases  of  malignant 
disease  where  the  latter  is  limited  to  the  upper  jaw,  and  to  gain  access  to 
nasopharyngeal  tumors  (temporary  osteoplastic  resection). 

Operation  (Fergusson, Weber)  .—The  incisor  teeth  of  the  correspond- 
ing side  are  extracted.  The  incisions  commence  by  dividing  the  upper  lip 
in  the  median  line.  The  incision  continues  on  around  the  ala  and  thence  on  the 
side  of  the  nose  to  the  inner  canthus  of  the  eye  (F  e  r  g  u  s  s  o  n).  From  this 
point  it  is  carried  along  the  infraorbital  margin  (Weber)  and  to  the  malar 
bone  if  necessary  (Fig.  314).     The  flap  thus  marked  out  is  dissected  from  the 


Fig.  314. — Lines   op   Incision  for  Resection  of  the 
Upper  Jaw. 


538 


THE    SURGERY    OF   THE    HEAD 


Fig.  315. — Resection  of  Half  of  the   Upper  Jaw. 
Dissection  of  the  flap  from  the  bone. 


Fig.  316. — Lion-jaw  Forceps  Grasping  the  Resected  Portion  of  the  Upper  Jaw. 


THE    JAWS 


539 


bone  (Fig.  315).  A  narrow  saw  is  passed  into  the  nostril  and  the  alveolar 
process  and  hard  palate  are  divided.  The  saw  is  now  reversed  and  the  nasal 
process  of  the  bone  divided  in  a  direction  upward  and  outward.  The  point  of 
the  saw  is  now  carried  along  the  thin  floor  of  the  orbit  to  the  malar  process  or  to 
the  malar  bone  itself,  if  necessary,  which  is  then  sawed  through.  In  benign 
tumors  the  orbital  plate  may  be  spared.  These  bone  sections  are  completed 
with  the  bone-forceps.  The  mucous  membrane  of  the  roof  of  the  mouth  is  now 
incised  as  far  back  as  the  soft  palate  in  the  line  of  the  bone  section.  The  bone 
is  grasped  with  the  lion  forceps  (Fig.  316),  forcibly  pried  away  from  the  ptery- 
goid process  and  palate  bone,  and  detached  with  the  scissors  from  its  remaining 
attachments  to  the  soft  parts  (orbital  fascia,  infraorbital  nerve,  and  soft  palate). 
Hemorrhage  is  arrested  by  the  ligature,  the  thermocautery,  and  packing  with 
antiseptic  (zinc  oxid)  gauze.  The 
edges  of  the  soft  parts  are  adjusted 
by  interrupted  sutures  of  silkworm- 
gut. 

Septic  complications  are  to  be 
combated  during  the  after-treatment 
by  swabbing  out  the  wound  cavity 
with  a  5  per  cent  solution  of  zinc 
chloric!  at  the  first  four  or  five  re- 
clressings.  Daily  redressings,  spray- 
ing with  hydrogen  dioxid,  and  irri- 
gating the  parts  with  a  1 :  1000  solu- 
tion of  permanganate  of  potassium 
or  Thiersch's  solution  are  neces- 
sary. 

The  dentist's  art  will  materially 
aid  in  supplying  the  lost  parts,  both 
for  cosmetic  and  functional  pur- 
poses. Visual  disturbances  may 
occur  from  displacement  of  the  globe. 

Simultaneous  removal  of  both 
superior  maxillas  has  been  per- 
formed for  rapidly  growing  sarcoma, 
extending  from  one  jaw  to  the 
other.     This  may  be  accomplished  by 

means  of  the  Lizar-Velpeau  incision  (Fig.  317)  applied  on  each  side. 
The  entire  facial  soft  structures  of  each  side,  including  the  upper  lip,  are  dis- 
sected loose  from  the  bone  and  turned  up  as  one  flap.  Or.  the  Fergusson- 
Weber  incision  already  described  may  be  employed,  applied  on  both 
sides.  In  this  case  two  facial  flaps  are  formed.  The  hard  palate  need  not  be 
divided.  The  .saw  is  applied  so  as  to  divide  the  frontal  process  of  one  malar 
bone;  thence  it  passes  through  the  corresponding  orbital  plate  and  across 
the  root  of  the  nose;  finally,  it  divides  the  orbital  plate  of  the  other  side  and 
the  remaining  malar  bone. 

Removal  of  both  superior  maxillas  in  two  sittings  is  sometimes  indicated 
in  cases  of  phosphorus  necrosis.  The  portion  most  advanced  in  disease  is 
first  removed.     After  several  months  the  remaining  jaw  is  removed. 


Fig.  317. — The  Lizar-Velpeatt  Incision  Applied 
TO  Both  Sides  for  the  Simultaneous  Re- 
moval or  Both  Superior  Maxillas. 


540  THE  SURGERY  OF  THE  HEAD 

THE  NERVES  OF  THE  FACIAL  REGION 

The  nerves  of  the  facial  region  are  affected  with  neuralgia  in  the  following 
order  of  frequency:  (1)  supraorbital;  (2)  inferior  maxillary;  (3)  infraorbital; 
(4)  frontal;    (5)  lingual. 

Tic  douloureux,  or  neuralgia  of  the  fifth  nerve  accompanied  by  muscular 
spasm  of  the  affected  region,  may  be  a  symptom  of  peripheral  nerve  lesion, 
this  being  situated,  as  a  rule,  in  a  cicatrix  of  the  alveolar  margin.  It  is  par- 
ticularly liable  to  occur  in  the  eruption  of  the  lower  wisdom  tooth.  In  case  the 
point  of  original  injury  and  the  (;onsequent  cicatrix  can  be  determined,  resec- 
tion of  the  parts  is  indicated  (see  page  545). 

Simple  division  of  the  branches  of  the  trigeminus  (neurotomy)  at  the  point 
where  they  leave  the  bony  canal  is  useless;  relapse  occurs  in  the  vast  majority 
of  cases.  In  this  connection,  therefore,  only  those  methods  which  are  calcu- 
lated to  afford  some  hope  of  permanent  relief  will  be  considered. 

Neurectomy  of  the  Infraorbital  Nerves  and  Superior  Maxillary 
Nerve. — This  nerve  is  attacked  either  at  its  place  of  exit  at  the  infra- 
orbital foramen,  in  the  infraorbital  canal,  or  at  the  foramen  rotundum 
in  the  sphenomaxillary  fossa,  beyond  the  ganglion  of  Meckel.  The  infraor- 
bital foramen  corresponds  to  the  upper  limit  of  the  canine  fossa  and  is  on  a 
vertical  line  dra^vn  directly  upward  from  the  fissure  between  the  first  and  the 
second  superior  molar.  A  curved  incision  is  made,  parallel  to  the  infraor- 
bital margin  and  just  below  the  latter;  this  separates  the  fibers  of  the  orbi- 
cularis palpebrarum.  On  reaching  the  deeper  portions  of  the  canine  fossa 
the  fibers  of  the  levator  anguli  oris  are  encountered,  passing  in  a  vertical 
direction.  This  muscle  may  be  separated  in  the  direction  of  its  fibers,  if  not 
too  thick;  otherwise  the  latter  may  be  divided.  The  leash  of  nerves  arising 
from  the  division  of  the  nerve-trunk  as  it  emerges  upon  the  face  is  now  to  be 
identified  and  dissected  from  the  flap.  The  foramen  may  be  readily  found  by 
following  the  nerve  branches  in  a  central  direction.  A  ^-inch  trephine  is  now 
applied  to  the  wall  of  the  antrum  of  Highmore  with  its  edge  just  below  the 
foramen,  or  the  wall  may  be  chiseled  away.  Access  is  thus  gained  to  the  an- 
trum. A  V-shaped  piece  is  to  be  chiseled  away  from  the  margin  of  the  orbit 
at  the  site  of  the  foramen,  the  nerve-trunk  loosened,  and  j  inch  or  more 
removed  at  this  point.  To  resect  the  superior  maxillary  nerve  the  trunk  is 
followed  along  the  infraorbital  canal,  the  walls  of  the  latter  being  chiseled 
away  for  that  purpose.  A  head  band  mirror  reflecting  light  into  the  antrum, 
will  be  useful  at  this  stage  of  the  operation.  The  posterior  wall  is  perfor- 
ated with  a  |-inch  trephine,  with  its  point  withdrawn,  and  the  sphenomaxil- 
la.T}'  fossa  entered.  Hemorrhage  is  to  be  arrested  by  pressure  and  section  of 
the  nerve  made  by  means  of  double  curved  scissors  close  to  the  edge  of  the 
foramen  rotundum.  The  resected  portion  of  nerve  is  withdra^nl  and  the 
thermocautery  applied,  if  the  hemorrhage  persists  in  the  fossa.  This  serves, 
also  to  effect  destruction  of  the  ganglion  of  Meckel,  and  the  palatine  nerves 
passing  thereto.  The  cavity  is  to  be  packed  and  the  external  Avound  par- 
tially closed  by  suturing. 

Method  by  Means  of  Temporary  Resection  of  the  Malar  Bone.^ — This 
method,  introduced  by  Liicke,  of  Strasburg,  is  as  foDows:  An 
incision  is  made  from  the  middle  of  the  external  orbital  edge  do\Miward  and 


THE    XERVES  OF  THE   FACIAL   REGION  541 

toward  the  median  line,  terminatinji:  near  the  root  of  the  third  molar.  This 
is  carried  down  to  the  bone.  The  malar  bone  is  freed  from  periosteum  at  both 
its  anterior  and  its  posterior  surface,  and  a  chain  saw  passed.  The  bone  is 
now  di\-ided  from  behind,  forward  and  inward.  A  second  incision  begins 
at  the  lower  angle  of  the  first,  is  carried  to  the  lower  edge  of  the  malar  bone, 
and  thence  to  the  junction  of  the  zygomatic  arch  and  the  temporal  bone. 
The  zygomatic  arch  is  separated  by  means  of  a  chisel  or  the  cutting  bone 
forceps.  The  insertion  of  the  masseter  at  the  malar  bone  is  detached,  when 
the  entire  flap,  consisting  of  bone  and  soft  parts,  is  turned  upward  by  means 
of  retractors.  By  displacing  outwardly  the  temporal  muscle,  the  infraor- 
bital fissure  is  reached  and  resection  of  the  nerve  performed  at  this  point. 
On  account  of  injury  of  the  masseter,  which  interferes  afterward  \\'ith 
opening  the  mouth,  it  has  been  proposed  (L  o  s  s  e  n  ,  B  r  a  u  n)  to  carry 
the  horizontal  incision  of  L  ii  c  k  e  above  instead  of  below  the  malar 
bone.  A^'ulsion  of  the  nerve  may  be  performed  (T  h  i  e  r  s  c  h),  or  twist- 
ing and  avulsion  combined  fB  r  a  u  n).  through  either  of  these  incisions. 

Neurectomy  of  Second  and  Third  Divisions  of  the  Fifth  Nerve 
with  Avulsion  of  the  Qasserian  Ganglion.— An  omega-shaped  incision 
is  made  having  its  base  at  the  zygoma  and  measuring  a  distance 
marked  by  a  line  dvsLwnn.  from  the  external  angular  process  of  the  fron- 
tal bone  to  the  tragus.  The  curved  upper  portion  reaches  to  the  supra- 
temporal  ridge.  An  osteoplastic  resection  of  the  bone  is  made  by  chisel- 
ing a  groove  on  the  same  lines,  the  bone  breaking  at  the  base  of  the 
omega  and  the  soft  parts  serving  as  a  hinge  to  the  trapdoor-like  flap  which 
is  turned  down.  The  dura  and  brain  are  raised  from  the  floor  of  the  middle 
fossa  of  the  skull  by  retractors,  and  both  the  foramen  rotundum  and  ovale 
exposed,  together  ^dth  the  second  and  third  divisions  of  the  fifth  nerve.  By 
forcing  back  the  dura  at  the  front  where  the  second  and  third  divisions  of  the 
fifth  nerve  pass  through  the  foramen  rotundum  and  the  foramen  ovale,  these 
branches  are  divided  close  to  the  bone.  The  central  ends  of  the  divided  nerves 
are  grasped  by  forceps  and  excised  or  a\ailsed  to  a  point  beyond  the  Gasserian 
ganglion.  The  osteoplastic  flap  is  now  replaced  and  united  by  sutures 
(K  r  a  u  s  e  ,     Hartley). 

Various  modifications  of  the  above  method  have  been  introduced.  The 
best  of  these  is  that  of  intracranial  neurectomy  de\dsed  by  A  b  b  e  ,  in  which 
a  vertical  incision  over  the  middle  of  the  zygoma  and  the  remoA^al  of  sufficient 
of  the  temporal  bone  to  give  access  to  the  site  of  the  Gasserian  ganglion 
replace  the  omega-shaped  osteoplastic  flap  of  Krause  and  Hart  fey. 
The  second  division  is  resected  at  the  foramen  rotundum  and  the  third  division 
at  the  foramen  ovale.  In  order  to  prevent  reunion  of  the  divided  nerve-trunks 
a  piece  of  sterihzed  rubber  tissue  is  implanted  over  the  foramen  ovale  and  the 
foramen  rotundum  after  resection  of  the  nerves  (Fig.  318). 

The  following  points  should  be  borne  in  mind  in  conducting  the  operation: 
(1)  The  incision  should  be  of  sufficient  length  to  permit  easy  retraction  of  its 
edges.  (2)  The  soft  parts,  including  the  periosteum,  should  be  well  cleared 
to  and  somewhat  below  the  level  of  the  zygoma.  (3)  The  preliminary  trephine 
opening  should  be  immediately  opposite  the  foramen  ovale.  This  will  be  on  a 
line  drawn  vertically  from  just  in  front  of  the  condyle  of  the  lower  jaw.  (4) 
In  enlarging  the  opening  with  the  gouge  forceps  this  should  be  confined  as  much 


542 


THE    SURGERY    OF   THE    HEAD 


as  possible  to  the  squamous  portion  of  the  temporal  bone.  Encroachment  upon 
the  area  beyond  this  is  sometimes  followed  by  troublesome  hemorrhage  from 
the  vessels  in  the  diploe.  If  this  is  unavoidable,  however,  the  flow  of  blood  may 
be  usually  arrested  by  grasping  the  edge  of  the  bone  at  the  site  of  the  bleeding 
by  a  rongeur  forceps  and  crushing  the  diploe.  (5)  In  separating  the  dura 
from  the  base  this  should  be  done  by  the  finger.  The  separation  should  be 
carried  on  systematically  and  continuously  without  regard  to  the  hemor- 
rhage until  the  finger  encounters  the  flattened  out  trunk  of  the  third  division, 
which  is  usually  easily  recognized  by  the  touch  at  the  foramen  ovale.  The 
brain  is  then  lifted  from  the  base  of  the  skull  by  the  retractor  (either 
Hartley's  or  the  one  shown  in  the  illustration,  see  Fig.  318),  the  blood 
cleared  away  by  rapid  sponging,  and  the  parts  thoroughly  packed  with  iodo- 
form gauze.  This  is  removed  and  replaced  at  intervals  of  five  minutes  or  less 
until  the  bleeding  ceases.     (6)  The   third  division  at  the  foramen  ovale  is 

first  caught  up  by  a  blunt  hook 
and  drawn  out  as  far  as  possible. 
The  nerve  is  then  grasped  by  a 
narrow  bladed  forceps  on  the 
foramen  side  of  the  hook  and 
divided  between  the  two,  as  close 
to  the  ganglion  as  possible.  By 
traction  on  the  peripheral  stump 
by  means  of  the  forceps,  from  an 
eighth  to  a  quarter  of  an  inch  of 
the  nerve-trunk  is  dragged  out 
of  the  foramen  and  removed. 
The  second  division  at  the  fora- 
men rotundum  is  dealt  with  in 
the  same  manner.  (7)  Under  no 
circumstances  should  the  pressure 
exercised  b}"  the  retractor  in  lift- 
ing the  brain  from  the  base  of 
the  skull  be  kept  up  for  more 
than  two  or  three  minutes  at  a 
time,  on  account  of  the  damaging 
effects  of  the  compression  on  the  cerebral  substance,  and  of  the  prolonged 
displacement  of  the  cerebrospinal  fluid.  The  respiratory  center  is  especially 
likely  to  be  unfavorably  influenced  by  the  latter,  as  shown  by  the  shallow 
breathing  of  the  patient. 

Neurectomy  of  the  Inferior  Dental  Nerve.— The  nerve  is  to  be  reached 
at  its  entrance  into  the  bony  canal.  The  nerve  lies  about  in  the  middle  line  of 
the  jaw,  except  in  old  people,  when  it  lies  more  inferiorly.  It  enters  the  bone 
about  I  of  an  inch  above  a  line  drawn  from  the  point  of  the  projecting  angle  of 
the  jaw  to  the  center  of  the  receding  angle  within  the  cavity  of  the  mouth. 

In  order  to  expose  the  nerve  a  flap  is  formed,  with  its  base  upward,  its  sides 
corresponding  to  the  anterior  and  posterior  edges  of  the  ramus  of  the  jaw.  The 
masseter  attachment,  together  with  the  periosteum,  is  separated  and  the  sur- 
face of  the  bone  exposed.  A  portion  of  the  bone  is  chiseled  away,  or  the 
trephine  is  applied  and  a  button  of  bone  removed ;  the  bone  is  further  chiseled 


Fig.  318. — Abbe's  Intracranial  Neurectomy. 


THE    NEUA'KS    OF   Till']    FACIAI.    IIEGION  543 

away  in  an  upward  direct  ion.  Tlie  norA-e  can  scarcely  be  separated  from  the 
artery,  and  tlierefore  both  are  generally  severed.  A  j)iece  of  the  nerve  is 
resected  and  the  hemorrhage  arrested  by  pressure.  II'  the  themocautery  is 
employed  hi  the  section,  hemorrhage  is  avoided  (H  u  e  t  c  r).  The  fhi})  is 
replaced  and  sutured. 

Methods  without  Chiseling  the  Bone. — An  incision  is  made  along  the 
posterior  edg(>  of  the  ramus  of  the  jaw  down  to  the  periosteum,  which  is  lifted. 
The  internal  pterygoid  insertion  is  divided  with  scissors.  The  spine  of  Spix 
is  identified  by  means  of  the  index-finger,  and  with  the  latter  as  a  guide  the 
nerve  is  hooked  at  the  point  at  which  it  enters  the  inferior  dental  foramen. 
The  nerve  is  drawn  out  into  the  external  wound  without  being  divided,  after 
which  an  inch  or  more  may  be  resected.  Or  the  same  result  may  be  obtained 
b}'  an  incision  along  the  angle  of  the  jaw  (S  o  n  n  e  n  b  u  r  g). 

In  the  first  mentioned  method  the  cosmetic  effect  is  inferior  to  that  of  the 
second.  On  the  other  hand,  in  the  two  last  mentioned  methods  the  divi- 
sion of  the  pterygoid  constitutes  an  objection  from  the  point  of  view  of 
function. 

In  some  cases  in  which  intractable  neuralgia  persists  after  resection  of  the 
inferior  dental  nerve,  it  will  be  necessary  to  reach  the  third  division  of  the  fifth 
pair  at  its  exit  from  the  foramen  ovale,  or  this  may  be  performed  at  the  outset. 

Intrabuccal  Methods. — The  mouth  is  opened  widely  and  the  coronoid 
process  identified.  The  mucous  membrane  is  incised  at  tliis  point  from  above 
downward,  the  soft  parts  pushed  away  from  the  bone,  and  the  spine  of  Spix 
felt  for  with  the  index-finger.  The  nerve  is  then  hooked  up  and  resected. 
Only  a  small  portion  can  be  removed  by  this  method,  and  a  pocket  for  the 
accumulation  of  pus  is  left. 

Method  by  Temporary  Resection  of  the  Lower  Jaw. — The  jaw  is  exposed 
by  an  incision  commencing  in  front  of  the  mastoid  and  extending  first  down- 
ward along  the  sternomastoid  to  the  cornu  of  the  hyoid  bone,  and  from  here 
upward  and  forward  until  it  reaches  the  point  of  insertion  of  the  masseter.  The 
bone  is  divided  just  posterior  to  the  last  molar  by  means  of  a  G  i  g  1  i  saw,  the 
internal  pterygoid  muscle  severed,  and  the  two  halves  of  the  jaw  reflected; 
the  cavity  of  the  mouth  should  not  be  opened.  The  process  of  Spix  is  now  to 
be  identified;  just  below  this  short  spine  and  posterior  to  it  the  nerve  enters  the 
dental  canal.  Here  it  is  hooked  up  and  secured  by  passing  a  thread  around 
it.  It  is  now  divided  close  to  the  bone  and  drawn  out  with  the  thread  so  that 
it  can  be  followed  up  to  the  foramen  ovale.  The  chorda  tympani  is  to  be 
avoided.  After  section  of  the  nerve  at  the  foramen  ovale  it  will  be  found  still 
held  by  its  gustatory  branch  passing  to  the  tongue.  The  point  where  the 
chorda  tympani  joins  the  gustatory  should  be  identified  and  the  latter  severed 
move  this.  The  jaw  is  to  be  wired  and  the  wound  closed  except  where  the 
wire  emerges. 

In  order  to  secure  proper  articulation  of  the  teeth  the  services  of  a  den- 
tist should  be  employed  to  make  an  interdental  splint  before  the  section  of 
the  jaw  is  made.     This  is  to  be  employed  in  the  after-treatment. 

Method  by  Temporary  Resection  of  the  Malar  Bone  (S  a  1  z  e  r).— 
A  curved  incision  with  its  convexity  upward  extends  along  the  entire  length 
of  the  malar  bone.  The  skin,  fascia,  periosteum,  and  temporal  muscle  are 
divided.     The  bone  is  divided  at  each  end  and  the  temporal  muscle  loosened 


544  THE  SURGERY  OF  THE  HEAD 

from  the  skull.  The  flap,  consisting  of  the  skin,  muscle,  and  bone,  is  now- 
retracted  downward.  The  nerve  is  separated  from  the  middle  meningeal 
artery,  divided  close  to  the  foramen  and  a  portion  resected.  The  coronoid 
process  of  the  inferior  maxilla  is  kept  out  of  the  wa}"  by  opening  the  mouth 
widely.  The  vessels  in  the  pterygoid  fossa  lie  beneath  the  field  of  operation, 
and  the  external  pterygoid  muscle  is  uninjured.  The  parts  are  to  be  replaced 
and  sutured  as  in   L  ii  c  k  e  '  s   operation   (page  540). 

Method  without  Bony  Resection. — The  incision  is  carried  in  a  curved 
direction  from  f  of  an  inch  above  the  angle  of  the  jaw  to  a  point  in  front  of 
the  facial  arter}'-,  where  the  latter  crosses  the  bone.  The  parotid  gland  is 
loosened  from  the  parotido-masseteric  fa.scia  and  retracted  in  an  upward 
direction.  .  The  internal  pterygoid  muscle  is  separated  at  its  insertion  at  the 
angle.     The  guide  to  the  nerve  is  the  spine  of  8pix  (U  1  1  m  a  n  n). 

Neurectomy  of  the  Supraorbital  Nerve. — Neuralgia  of  this  nerve 
occurs  next  in  frequency.  It  is  sometimes  the  result  of  an  inflammatory 
swelling  of  the  periosteum  lining  the  short  canal  in  which  it  lies  at  the  supra- 
orbital ridge. 

An  incision  is  made,  following  the  line  of  the  supraorbital  ridge.  The 
skin  and  orbicularis  palpebrarum  are  separated  from  the  bone,  as  well  as  the 
external  portion  of  the  superior  tarsal  cartilage.  By  pushing  back  the  fat 
and  connective  tissue  in  the  orbit  the  roof  of  the  latter  is  brought  into  view. 
The  nerve  is  now  isolated  from  the  adipose  and  connective  tissues,  when  a 
piece  If  inches  long  may  be  removed.  The  wound  may  be  sutured  in  its 
entire  length;  primary  union  is  the  rule. 

Intraneural  injections  of  osmic  acid  have  been  employed  in  intract- 
able facial  neuralgia  (Bennett).  Temporary  relief  may  be  some- 
times obtained  by  this  method,  lasting  for  months,  and  exceptionally  for 
longer  periods  of  time.  The  method  is  indicated  in  the  aged  and  in  those 
in  poor  physical  condition.  A  general  anesthetic  may  be  administered,  or 
local  anesthesia  may  be  secured,  and  the  branches  of  the  fifth  nerve  exposed. 
In  the  case  of  the  supraorbital  nerve  the  incision  is  made  over  the  supraorbital 
notch  and  parallel  with  the  eyebrow.  The  infraorbital  is  reached  most  easily 
by  a  curved  incision  at  the  site  of  the  infraorbital  foramen.  To  avoid  de- 
formity, however,  the  nerve  should  be  reached,  whenever  possible,  by  forcible 
retraction  of  the  upper  lip,  incision  of  the  mucous  membrane  of  the  mouth 
and  dissection  of  the  structures  covering  the  superior  maxilla.  The  mental 
branch  of  the  inferior  dental  is  reached  at  the  mental  foramen  by  retraction 
of  the  lower  lip  and  an  incision  through  the  mucosa. 

The  nerve  is  elevated  by  a  blunt  hook,  and  from  5  to  15  minims  of  a  freshly 
prepared  1.5  per  cent  solution  injected  directly  into  the  nerve  by  means  of 
an  ordinary  hypodermic  syringe  and  fine  needle.  The  solution  is  injected 
in  several  places,  in  order  to  be  certain  that  every  portion  of  the  nerve  is 
reached,  and  finally  a  small  quantity  is  injected  between  the  nerve  and  its 
sheath  in  its  bony  canal   (J.   B.    Murphy). 

The  modus  operandi  of  the  procedure  is  not  definitely  understood.  It  should 
not  be  employed  in  neuralgias  of  nerves  with  important  motor  functions. 

Neurectomy  of  the  Lingual  Nerve. — Except  for  the  purpose  of 
relieving  the  pains  of  inoperable  carcinoma  of  the  tongue,  this  nerve  rarely 
requires  division,  compared  with  the  frequency  with  which  the  second  and 
third  divisions  of  the  trigeminus  are  operated  on. 


THE    TONGUE  545 

For  neuralgia  the  lino;ual  nerve  may  be  readily  reached  by  an  incision 
at  the  lateral  edge  of  the  tongue.  C  .  H  u  e  t  e  r  was  compelled  to  perform 
a  neurectomy  of  the  lingual  for  intractable  neuralgia  following  a  wound  of  the 
tongue  by  a  common  table  fork.  In  carcinoma  of  this  organ,  however,  the 
nerve  must  be  I'eached  at  a  higher  point.  This  may  be  accomplished  by  the 
same  incision  recommended  for  neurectomy  of  the  inferior  dental,  and  by 
chiseling  away  a  portion  of  the  receding  angle  of  the  inferior  maxilla  until  the 
spine  of  Spix  is  reached.     The  nerve  is  here  hooked  up  and  resected. 

Neurectomy  and  Stretching  of  the  Facial  Nerve.— Painful  spasm 
of  the  face  (tic  douloureux)  sometimes  i-equires  operative  interference.  The 
disease  is  characterized  by  continuous  convulsions  of  the  facial  muscles 
of  one  side.  In  some  cases  the  spasm  is  of  reflex  origin  and  depends  on  in- 
creased sensibility  of  the  branches  of  the  trigeminus.  Resection  of  the  nerve  is 
necessarily  followed  by  paralysis  of  the  facial  muscles  of  the  corresponding  side. 
Stretching  of  the  nerve  is  the  preferable  operation  and  should  be  first  tried. 
The  nerve  may  be  reached  through  an  incision  at  the  anterior  edge  of  the 
sternomastoid  insertion.  The  body  of  the  parotid  gland  is  drawn  toward 
the  front  by  blunt  retractors;  the  styloid  process  is  the  guide  to  the  nerve  at 
its  point  of  exit  from  the  stylomastoid  foramen. 

Hueter's  Method.— The  lobe  of  the  ear  is  separated  from  the  facial  skin 
by  a  vertical  incision  2  inches  long  at  the  posterior  edge  of  the  ramus  of  the 
jaw.  The  parotid  fascia  is  divided  and  the  parotid  gland  separated,  care  being 
taken  not  to  invade  the  region  behind  the  ramus,  where  the  external  carotid 
artery  may  be  wounded.  By  careful  dissection  the  mferior  I3 ranch  is  reached 
first,  which,  though  very  small,  may  be  recognized  by  its  curve  as  it  passes 
anteriorly.  Following  this  the  superior  branch  is  found,  passing  almost  hori- 
zontally and  meeting  the  first  at  an  acute  angle.  The  main  trunk  is  now 
followed  to  the  stylomastoid  foramen. 

The  nerve  may  be  stretched,  without  being  followed  to  the  foramen,  from 
the  point  of  union  of  the  upper  and  the  lower  branch.  The  paralysis  which 
follows  stretching  may  be  recovered  from;  the  original  spasm  frequently 
returns  at  the  same  time. 

Mimic  spasm  consists  of  continuous  convulsive  movements  of  the  facial 
muscles  of  one  side,  particularly  of  the  orbicularis  palpebrarum.  A  more  or 
less  constant  wuiking  occurs.  The  con^^dsions  are  usually  of  reflex  origin  and 
depend  on  an  exaggerated  irritability  of  the  sensitive  branches  of  the  tri- 
geminus nerve,  which  are  usually  ^'ery  sensitive  to  touch,  as  weU  as  painful. 
Pressure  on  a  sensitive  branch  at  its  place  of  exit  at  once  arrests  the  spasm. 
Surgical  treatment  will  sometimes  give  relief.  This  consists  in  a  neurectomy 
of  the  branch  involved. 

THE  TONGUE 

Examination  of  the  Oral  Cavity.— The  ordinary  tongue  depressor 
is  used  by  da^dight  for  purposes  of  inspection.  For  examination  in  a  dark 
room,  or  at  night,  the  combined  tongue  depressor,  candlestick,  and  reflector, 
or  the  electric  light  tongue  depressor,  is  useful  (Figs.  319  and  320).  The 
cheek  may  1)e  retracted  by  the  finger  placed  in  the  angle  of  the  mouth.  Special 
oral  specula  are  rarelv  necessary-  for  purposes  of  examination. 
36 


546 


THE    SURGERY   OF   THE   HEAD 


Palpation  of  the  organs  behind  the  hne  of  the  teeth  (tongue,  hard  and 
soft  palate,  and  tonsils)  is  of  value  in  cases  of  suspected  syphilitic,  tuberculous, 
or  carcinomatous  disease  of  these  organs,  and  should  never  be  omitted. 

Lacerated  wounds  of  the  tongue  from  violent  contact  with  the 
edges  of  the  teeth  occur  during  careless  mastication,  from  falls  on  the  chin 


Fig.  319. — Combined  Tongue  Depressor,  Candlestick,  and  Reflector. 


with  the  tongue  projecting  between  the  teeth,  and  in  epileptic  convulsions. 
Punctured  wounds  occur  from  the  presence  of  bone  splinters,  bits  of  glass, 
needles,  etc.,  in  the  food.  Gunshot  wounds  of  the  tongue  may  occur  in  con- 
nection with  simultaneous  injury  of  the  bone,  or  the  missile  may  enter  the 
cavity  from  the  suprahyoid  region,  the  head  being  forcibly  extended.     Burns 

and  scalds  of  the  tongue 
are  comparatively^  fre- 
quent but  not  likely  to  be 
severe. 

Treatment. — These  in- 
juries of  the  tongue  are 
neither  difficult  of  maii- 
agement  nor  dangerous  to 
life.  The  hemorrhage, 
which  may  be  considera- 
ble, is  usually  arrested  by 
a  few  deep  sutures.  Pain, 
which  may  be  severe,  is 
to  be  allayed  by  small 
pieces  of  ice  in  the  mouth. 
Suturing  is  facilitated  by 
passing  a  loop  of  thread 
through  the  organ  at  its  tip  and  pulling  it  forward.  In  consequence  of  the 
rich  blood-supply,  healing  usually  takes  place  by  primary  union. 

Inflammatory  edema  usually  marks  the  limit  of  the  reaction  following 
traumatism  of  the  tongue.  The  vital  resistance  of  the  organ  is  very  high, 
and  hence  marked  septic  processes,  such  as  phlegmonous  inflammation,  or  sup- 
puration extending  beyond  the  wound  surfaces  themselves,  are  rare.      In  slight 


Fig.  320. — Electric  Light  Tongue  Depressor. 


THE    TONGUE  547 

injuries  healing  may  take  i)Iacc  without  any  apparent  reaction  whatever.  In 
those  rare  cases  in  which  the  swelling  in  traumatic  glossitis  is  such  as  to  em- 
barrass respiration,  scarification  may  be  necessary,  the  branches  of  the 
lingual  nerve  at  the  lateral  aspects  being  avoided,  and  the  knife  being  entered 
slowly  and  superficially  to  avoid  the  branches  of  the  lingual  artery. 

Ulceration  occurs  on  the  lateral  aspect  of  the  organ  from  contact  with 
the  sharji  edges  of  a  tooth,  ajid  disappears  on  the  removal  of  the  latter.  A 
simple  localized  glossitis  may  arise  from  the  same  cause. 

Chronic  Glossitis.— This  includes  a  number  of  affections,  the  im- 
portant characteristic  of  which  is  a  change  of  form  and  overgrowth  of  the 
epidermis,  or  keratosis,     l^pithelioma  is  prone  to  develop  during  these  changes. 

Leukoplakia  (leukokeratosis)  is  a  name  given  to  the  white  patches 
on  the  tongue  and  buccal  mucous  membrane,  the  result  of  keratosis  or  corni- 
fication.  The  disease  has  its  origin  in  a  long-continued  chronic  glossitis. 
The  gouty  and  rheumatic  diathesis,  irritative  changes  from  syphilis,  and 
smoking  arc  thought  to  favor  the  development  of  the  affection. 

S3aiiptoms. — The  patient  frequently  is  not  aware  of  the  presence  of  the 
disease  in  the  beginning  until  the  peculiar  appearance  of  the  tongue  is  dis- 
covered by  accident.  As  the  disease  advances  there  may  be  burning  or  smart- 
ing when  hot  or  highly  spiced  food  is  taken.  Later  on,  the  comification  becomes 
thick  and  unyielding  and  gives  rise  to  considerable  discomfort  and  to  more 
or  less  interference  wdth  the  movements  of  the  tongue.  The  sense  of  taste 
is  affected  in  proportion  to  the  thickening  of  the  coating  and  its  area.  The 
affection  is  found  on  the  buccal  mucous  membrane,  and  particularly  on  the 
lining  of  the  lower  lip  and  near  the  angles  of  the  mouth.  The  patches  vary 
from  time  to  time  in  size  and  shape,  and  in  their  location  on  the  tongue  as 
well. 

Of  the  varieties  of  leukoplakia  the  most  important  are  (1)  so-called  syphili- 
tic psoriasis;  (2)  smoker's  patch;  (8)  simple  psoriasis;  (4)  ichthyosis,  an 
advanced  stage  of  the  affection  in  which  the  papillae  are  greatly  hypertrophied, 
giving  the  tongue  a  warty  appearance. 

The  diagnosis  is  usually  not  difficult.  The  chronicity  of  the  affection, 
its  almost  exclusive  occurrence  in  male  adults,  and  the  bluish-white  tint  of 
the  patch  are  sufficient  to  distinguish  it. 

The  prognosis  is  unfavorable  for  complete  cure.  In  addition,  the  cUsease 
offers  a  predisposing  cause  of  cancer.  The  latter  may  develop  after  the  leuko- 
plakia has  been  in  existence  for  many  j^ears. 

The  treatment  consists  of  abstention  from  all  foods  and  drinks  which 
tend  to  produce  irritation.  The  use  of  tobacco,  particularly  chewing  tobacco, 
must  be  forbidden  when  the  patches  are  spreading.  Alcoholic  drinks,  if  taken 
at  all,  must  be  largely  diluted.  Leukoplakia  of  syphilitic  origin  is  not  usually 
benefited  by  antisyphihtic  treatment.  It  is  a  postsyphilitic,  not  a  syphilitic, 
manifestation.  Alkaline  mouth-washes,  such  as  a  20-grain  solution  of  bi- 
carbonate of  potash,  give  the  greatest  relief  as  a  rule.  Solutions  of  chlorate 
of  potash,  and  hydrogen  dioxid  are  useful.  Syphilitic  cases  are  benefited 
most  by  applications  of  a  10  grain  to  the  ounce  solution  of  chromic  acid.  A 
mouth-wash  of  the  same  in  about  one-fifth  of  the  above  strength  may  be  used. 
The  patches  may  also  be  touched  with  a  10  per  cent  solution  of  potassium 
iodid.     Cold  cream  containing  borax  or  eucalyptus  acts  favorably  by  pro- 


548 


THE    SURGERY   OF   THE    HEAD 


tecting  the  surface.  All  sources  of  irritations  within  the  mouth,  such  as 
ragged  or  decayed  teeth,  should  be  removed.  If  ulcers  or  fissures  form,  total 
excision  of  the  affected  parts  is  to  be  recommended.  In  advanced  cases, 
and  because  of  the  dangers  of  the  supervention  of  malignant  disease,  destruc- 
tion of  the  cornified  area  with  the  thermocautery  is  advisable  (V  o  1  k  m  a  n  n). 
Tuberculous  ulceration  of  the  tongue  may  accompany  pulmonaiy 
tuljerculosis  or  occur  jjrimaril}-.  It  is  usually  situated  at  the  tip  near  the 
lateral  margin  and  is  more  frequently  observed  in  men  than  in  women.  It 
may  l^e  mistaken  for  carcinoma.  Extirpation  is  indicated  in  both  cases.  The 
diagnosis  may  be  established  by  microscopic  examination  of  a  portion 
removed  for  the  pvirpose.     Lupus  of  the  tongue  is  verv  rare. 

Abscesses  of  the  tongue  are  usually  the  result  of  a  breaking  down  of 
gummas.     They  are  situated  in  the  median  line,  and  as  a  rule  pursue  a  chronic 

course.  If  far  advanced,  the  usual  anti- 
syphilitic  treatment  of  iodid  of  potas- 
sium must  be  supplemented  by  incision 
and  curettage. 

Nonsyphilitic  phlegmon  (erysipelas 
of  the  tongue)  is  comparatively  rare. 
It  is  sometimes  ushered  in  by  chills  and 
vomiting.  The  sweating  may  be  consid- 
erable, as  in  traumatic  glossitis,  and  fin- 
ally subside,  or  eventuate  m  abscess. 
Early  openmg  of  the  latter  is  indicated. 
Scarifieation  is  useful  in  any  event. 

Deformities  of  the  Tongue. — The 
most  important  of  these  is  the  congenital 
giant  growth  (macroglossia).  This  oc- 
curs (1)  as  a  fibromyoma,  the  muscular 
structure  and  connective  tissue  being  ab- 
normally developed;  (2)  as  a  lymphan- 
giotna,  the  vessels  proliferating  into  the 
spaces.  The  tongue  may  be  so  large  as 
to  project  from  the  mouth  from  want  of 
space,  and  hang  down  as  a  dry,  fissured, 
or  ulcerated  mass,  which  bleeds  easily 
(Fig.  321).  The  incisor  teeth  become  loosened  and  crowded  forward  to  a 
horizontal  position.  An  acquired  similar  condition  following  erysipelas  of 
the  tongue  suggests  an  analogy  to  elephantiasis  following  erysipelas  of  a 
lower  extremity.  The  treatment  consists  in  excision  of  wedge-shaped  por- 
tions at  successive  sittings,  to  avoid  profuse  hemorrhage.  Pressure  by  means 
of  flat-bladed  forceps  behind  the  uicisions  will  control  the  bleeding  uiitil  deep 
sutures  can  be  taken.  Puncture  by  means  of  the  thermocautery  has  been 
used  successfully  (H  e  1  f  e  r  i  c  h). 

Congenital  ankyloglossia  or  tongue-tie  is  a  very  rare  condition.  When 
present,  it  is  due  to  a  defective  development  of  the  tongue,  rather  than  to  an 
excessive  development  of  the  frenum.  The  condition  will,  with  rare  excep- 
tions, correct  itself  with  the  growth  of  the  child.  Where  the  tongue-tie 
indubitably  interferes  with  sucking,  it  may  be  corrected  by  lifting  the  tongue 


Fig.   .321. — ^Macroolossia. 


THE    TONGUE  549 

with  the  index-finger  and  cutting  the  tense  fold  of  mucous  membrane  close  to 
the  floor  of  the  mouth  with  blunt  scissors.  Excessive  bleeding  is  to  be 
prevented  by  putting  the  child  to  the  breast  at  once.  Fatal  hemorrhage 
has  occurred  after  division  of  the  frenum.  Death  from  asphyxia,  due  to 
tongue-swallowing  (Petit)  and  macroglossia,  has  also  followed  this  operation 
(Sedillot,   Bollinger). 

Bifid  or  split  tongue  consists  of  a  longitudinal  fissure  which  divides  the 
forepart  of  the  tongue  into  two  unequal  parts.  The  split  may  extend  a  con- 
siderable distance  toward  the  root.  It  may  be  associated  with  a  cleft  lower 
lip,  with  arrest  of.  development  of  the  lower  jaw,  and  cleft  palate  or  harelip. 
The  opposed  surfaces  may  be  pared  aiid  brought  together  with  sutures. 

Acquired  ankyloglossia  is  the  result  of  cicatricial  thickening  of  the  frenum 
following  ulceration  occurring  in  the  course  of  the  eruption  of  the  incisors. 
The  mucous  membrane  on  each  side  of  the  frenum  becomes  irritated  by  con- 
tact with  the  sharp  edges  of  the  teeth  as  they  first  appear.  Later  on,  as  the 
teeth  advance,  the  pressure  ceases  and  the  ulceration  heals,  leaving  the  frenum 
contracted.     The  treatment  is  the  same  as  in  congenital  tongue-tie. 

Cancer  of  the  Tongue. — This  occurs  most  frequently  after  the  fortieth 
year.  Among  4600  cases  of  cancer  collected  byJessett,  over  8.7  per  cent 
w^ere  cases  of  cancer  of  the  tongue.  This  relative  frequency  is  explained  by 
the  exposure  of  the  tongue  to  "\^arious  sources  of.  irritation.  The  proportion 
of  men  to  women  attacked  is  85  per  cent.  This  is  attributed  to  the  habit  of 
smoking,  though  the  role  which  the  latter  plays  in  the  causation  is  probably 
exaggerated.  Its  occurrence  is  commonly  ascribed  to  friction  against  a  carious 
tooth  with  rough  edges.  The  most  common  location  for  its  fi.rst  appearance 
is  on  one  or  the  other  side  of  the  tip ;  it  is  occasionally  observed  on  the  dorsum, 
but  it  is  never  found  in  the  median  line  of  the  organ.  Leukoplakia,  syphilitic 
ulcer,  and  ichthyosis  are  noted  as  of  rather  frequent  occurrence  precedent  to 
epithelioma  of  the  tongue. 

Lymphatic  glandular  infection  occurs  early,  dissemination  is  not  common, 
and  death  frequently  takes  place  within  a  year. 

The  disease  occurs  in  the  ulcerative  and  the  infiltrated  forms.  The 
former  involves  rapid  destruction,  while  the  latter  is  characterized  by  the 
appearance  of  nodules  varying  in  size  from  a  pea  to  a  hazelnut,  which  appear 
deeply  embedded  in  the  muscular  substance  of  the  organ  along  its  lateral 
margins.  These  finally  ulcerate,  after  which  the  progress  is  very  rapid,  the  dis- 
ease extending  in  all  directions. 

Symptoms. — There  is  a  large  increase  of  the  saliva  from  reflex  irritation 
of  the  salivar}^  glands.  Decreased  mobility  of  the  tongue,  difficult  degluti- 
tion, and  embarrassment  of  speech  are  prominent  features.  Pain  is 
-marked.  It  occurs  early  in  the  disease,  is  radiating  in  character,  and  is 
propagated  from  the  lingual  branch  of  the  mferior  maxillar}'  division  of  the 
fifth  nerve  to  the  other  sensory  branches  of  this  division  (auriculotemporal 
and  inferior  dental).  A'iolent  pains  are  complained  of  in  the  external 
auditory  meatus  and  the  temporal  and  submaxillary  regions  of  the  affected 
side. 

The  patient  is  liable  to  fatal  hemorrhage  from  the  lingual  or  carotid  arters^, 
or  life  may  be  destroj'ed  by  septic  pneumonia,  asjohyxia  from  edema  of  the 
glottis,  the  pressure  of  massive  cervical  glands  on  the  trachea,  or  from  septico- 
anemia,  exhaustion,  and  semistarvation  combined. 


550 


THE   SURGERY   OF   THE   HEAD 


The  prognosis  is  doubtful  at  best.  It  is  most  favorable  if  removal  is 
accomplished  before  lymphatic  involvement.  The  mortahty  after  operation 
is  10  per  cent,  the  causes  of  death  being  hemorrhage  and  septic  pneumonia. 
The  liability  to  recurrence  is  very  great.  The  latter  takes  place  in  the  stump 
or  in  the  cervical  glands  withhi  a  year.  In  cases  otherwise  inoperable  neurec- 
tomy of  the  lingual  nerve  will  relieve  the  pain  and  excision  of  both  external 
carotids  and  their  branches  (D  a  w  b  a  r  n)  may  serve  to  hold  the  disease  in 

check. 

Diagnosis.— The  character  of  the  pains  and  their  distribution  are  of  diag- 
nostic importance.  The  ulcerative  variety  may  be  mistaken  for  syphilitic 
ulcer  and  the  infiltrated  variety  for  gumma.  In  the  former,  induration  of 
the  lingual  substance  will  be  less  marked  than  in  carcinoma;  in  the  latter, 
the  nodules  will  occupy  the  median  portion  of  the  tongue  and  there  will 
be  an  absence  of  the  characteristic  pains.     If  no  impression  is  made  on  the 

growth  in  fourteen  days 
by  the  internal  adminis- 
tration of  iodic!  of  potas- 
sium and  inunctions  of 
mercurial  ointment,  car- 
cinoma is  to  be  suspected 
and  a  section  removed 
for  microscopic  examina- 
tion. Tuberculous  ul- 
ceration rarely  occurs 
without  the  presence  of 
other  tuberculous  foci. 

The  Operative 
Treatment  of  Carci= 
noma  of  the  Tongue. 
— The  exceedingly  rapid 
course  which  carcinoma 
of  the  tongue  pursues,  as 
well  as  the  early  lym- 
phatic involvement,  de- 
mands prompt  operative 
interference.  Above  all 
things,  the  appHcation  of  nitrate  of  silver  or  other  caustic  substances  is  to  be 
avoided.  Such  apphcations  involve  loss  of  time  and  favor  further  growth  by 
their  irritating  effects. 

When  the  disease  is  superficial  and  situated  near  the  tip  of  the  tongue, 
a  large  cuneiform  piece  may  be  excised.  The  entire  organ  should  be  drawn 
well  forward  by  two  stout  ligatures  passed  well  back  at  the  base  (Fig.  322). 
The  part  to  be  removed  is  grasped  by  forceps,  the  frenum  divided,  the  entire 
tongue  brought  well  forward,  and  a  V-shaped  piece  excised.  On  account  of 
the  tendency  to  focal  proliferation,  the  limits  of  the  portion  to  be  excised 
should  be  first  marked  out  on  the  mucous  membrane  of  the  dorsum  of  the 
tongue  with  a  scalpel,  from  a  fourth  to  three-eighths  of  an  inch  of  healthy  tis- 
sue being  included.  The  gap  left  after  the  excision  should  be  sutured  at  once. 
If  a  large  portion  is  to  be  removed  the  sutures  may  be  passed  preliminarily. 


Fig.  322. — V-shaped  Excision  of  Tip  of  the  Tongue. 


THE   TONGUE 


551 


In  tlie  average  case,  liowevcr,  nothing  short  of  extirpation  of  half  of  the 
tongue  will  suffice  in  indubitable  cancer  of  the  organ.  In  still  more  advanced 
cases,  with  extensive  ulcerative  carcinoma,  or  deep  nodular  infiltration,  total 
extirpation  will  be  required.  When  the  floor  of  the  mouth  is  involved  and 
lymphatic  glandular  involvement  present,  the  operation  nuist  be  extended 
so  as  to  include  these. 

In  cases  otherwise  inoperable  the  removal  of  a  portion  of  the  lingual 
nerve  will  serve  for  a  time  to  arrest  the  pain.  Excision  of  the  external  caro- 
tid artery  on  each  side  for  the  purpose  of  inhibiting  the  growth  of  malignant 
disease  in  the  area  of  distribution  of  this  vessel  has  been  followed  by  en- 
couraging results  in  the  hands  of  the  originator  of  the  method.  Prof. 
D  a  w  b  a  r  n. 

The  Hemorrhage.— When  the  whole  tongue  is  to  be  removed,  one  or  both 
lingual  arteries  may  be  tied  primarily.  When  carcinomatous  glands  in  the 
neSv  are  to  be  removed,  this  should  be  done  before  the  tongue  is  excised, 
and  the  Unguals  tied  at  the  same  time,  provided  the  wound  in  the  neck  does 
not  communicate  with  the  cavity  of  the  mouth.  Otherwise  the  Unguals 
should  be  tied  as  they  are  divided,  owing  to  the  septic  complications  which  are 
likely  to  ensue  and  the  consequent  dangers  of  secondary  hemorrhage. 

Asphyxia  from  the  passage  of  blood  into  the  trachea  is  one  of  the  dangers 
to  be  feared.  Whitehead  prevents  this  by  placing  the  patient  in 
a  semisitting  position  with  the  head  held  forward.  The  Trendelen- 
burg position,  as  adopted  by  Keen  for  laryngectomy,  or  Rose's 
hanging  head  position  for  cleft  palate  operations,  serves  a  useful  purpose  in 
severe  cases.  The  venous  oozing  is  increased  by  these  measures,  however. 
In  the  majority  of  cases  the  patient  may  be  placed  on  the  side  with  the  angle 
of  the  mouth  firmlv  pressed  down  by  an  assistant.  Preliminary  tracheotomy, 
or,  better  stih,  iaryngotomy  (Bond,  Butlin),  should  be  performed 
when  the  entire  tongue  is  to  be  removed. 

Whitehead's  Operation  for  Extirpation  of  Half  of  the  Tongue  (Modi- 
fied).—The  mouth  should  be  washed  out  with  antiseptic  solutions  for  a  few 
days  prior  to  the  operation  and  all  loose  or  carious  teeth  removed.  The 
head  should  be  somewhat  elevated  on  a  sand-bag  and  turned  to  one  side. 
Whitehead  operates  with  the  patient's  head  elevated  and  bent  for- 
ward. The  mouth  is  held  open  by  a  self-retaining  mouth-gag.  Chloroform 
should  be  administered  by  means  of  a  Junker's  inhaler  with  a  nasal 
tube.  A  stout  ligature  is  passed  through  the  base  of  the  tongue  on  the  sound 
side  and  another  through  the  tip  on  the  diseased  side  (Fig.  323).  The  opera- 
tor grasps  the  latter  and  the  former  is  given  in  charge  of  an  assistant.  When 
the  disease  does  not  encroach  upon  the  floor  of  the  mouth,  the  tongue  is 
-  split  at  once  along  the  raphe  to  the  base  by  first  cutting  through  the  mucous 
membrane  on  the  upper  and  lower  surfaces  and  then  forcibly  tearing  the  two 
halves  apart.  The  diseased  half  is  extirpated  by  first  dividing  the  attachments 
to  the  floor  of  the  mouth,  then  the  anterior  pillar  of  the  fauces,  and  finally 
making  a  transverse  section  well  behind  the  limits  of  the  growth.  ^  The  lingual 
artery  "is  secured  either  before  or  after  the  transverse  incision  is  completed. 
When  the  disease  encroaches  upon  the  floor  of  the  mouth,  the  frenum  is 
first  cut  through  well  in  front  of  the  limits  of  the  growth.  The  incision  is  now 
extended  along  the  tongue  laterally,  still  well  outside  the  diseased  area,  until 


552 


THE    SURGERY    OF   THE    HEAD 


the  anterior  pillar  of  the  fauces  is  reached,  when  the  latter  is  divided.  The 
diseased  half  is  now  brought  Avell  forward,  the  tongue  split  in  the  middle  line, 
and  the  muscular  structures  on  the  floor  of  the  mouth  cut  through.  When 
the  floor  of  the  mouth  is  deeply  affected,  the  sublingual  gland  is  removed. 
The  lingual  arter}-  is  secured,  and,  finally,  the  half  of  the  tongue  removed 
by  a  transverse  incision  with  the  scissors. 

In  order  to  control  the  bleeding  from  the  floor  of  the  mouth  gauze  sponges 
are  pressed  on  the  wound  surface  and  counter-pressure  made  with  the  hand 
beneath  the  chin.  After  the  vessels  are  secured  and  the  mouth  cleansed  the 
latter  is  sponged  out  with  a  zinc  chlorid  solution  (40  grains  to  the  ounce). 
The  mucous  membrane  on  the  dorsum  of  the  tip  is  secured  to  that  on  the  under 
surface  by  sutures,  in  order  to  prevent  the  tip  from  being  bound  down  in  the 
floor  of  the  mouth. 


Fig.  323.^ — Whitehead's  Operation  for  Excision  of  One-half  of  the  Tongue. 
Showing  Junker's  inhaler  in  use.     The  tube  leading  to  the  nose  should  be  longer  than  that  shown  in  the 

illustration. 


The  patient  is  placed  in  bed  with  the  head  turned  toward  the  affected  side. 
As  soon  as  he  recovers  from  the  anesthetic  he  is  propped  up  in  bed  and  allowed 
to  sit  up  in  a  chair  as  soon  as  practicable.  The  mouth  should  be  frequently 
irrigated  with  a  boric  acid  or  permanganate  solution  and  sprayed  with  hydro- 
gen peroxid.  To  assist  in  carrying  off  the  secretions  Trendelenburg 
carries  a  large  drainage-tube  through  the  floor  of  the  mouth. 

Whitehead's  Method  for  Extirpation  of  the  Entire  Tongue. — The 
tongue  is  brought  well  forward  and  secured  by  a  ligature  passed  through  its 
tip.  The  organ  is  then  separated  from  the  floor  of  the  mouth  by  blunt  scissors, 
and  the  anterior  pillars  of  the  fauces  are  divided.  The  lingual  arteries  are 
secured.  A  ligature  is  passed  through  the  glosso-epiglottidean  fold  behind 
the  point  of  transverse  section,  to  secure  the  stimip  and  draw  it  forward,  if 
necessary,  after  the  tongue  is  removed.     The  extirpation  is  now  completed. 


THE    TONGUE 


553 


The  parts  are  thoroughly  cleansed  by  swabbing  with  a  1  :  1000  solution  of  bin- 
iotlid  of  mercury  and  painted  with  an  iodoform  styptic  varnish.  This  is  made 
by  substituting  for  the  spirit  ordinarily  used  in  the  preparation  of  friar's  balsam 
a  mixture  of  1  volume  of  ether  and  10  volumes  of  turpentin,  to  which  iodoform 
is  added  to  saturation.  The  patient  is  fed  as  freely  and  as  early  as  possible, 
the  varnish  being  ap})lio(l  at  least  once  daily.  The  ligature  at  the  base  of  the 
tongue  is  either  fastened  to  the  teeth  or  kept  hanging  out  of  the  mouth  by 
the  weight  of  a  pair  of  forceps,  and  is  usually  removed  at  the  end  of  twenty-four 
hours. 

When  the  floor  of  the  mouth  is  extensively  diseased,  the  method  of  median 
section  of  the  lower  jaw  will  be  useful.  The  soft  parts  are  incised  vertically 
and  cleared  away  from  the  jaw  in  front  and  an  inch  or  more  on  each  side. 
The  bone  is  divided  at  the  symphysis  and  the  two  halves  forcibly  separated. 
The  tongue  is  now  secured,  drawn 
strongly  forward,  and  readily  ex- 
tirpated, together  with  the  dis- 
eased structures  in  the  floor  of  the 
mouth.  The  bone  is  replaced  and 
sutured  with  silver  wire,  drainage 
provided  for  through  the  floor  of 
the  mouth,  and  the  soft  parts 
united  with  sutures. 

Billroth  performed  a  temp- 
orary resection  of  the  median 
portion  of  the  lower  jaw. 

When  the  disease  extends  from 
the  base  of  the  tongue  and  in- 
volves the  surrounding  structures, 
the  organ  cannot  be  protruded. 
In  order  to  obtain  ready  access 
and  get  well  beyond  the  disease, 
one  of  the  extrabuccal  methods 
must  be  adopted.  The  simplest 
extrabuccal  method  is  that  of 
splitting  the  cheek.  The  inci- 
sion is  carried  through  the  entire 

thickness  of  the  cheek  from  the  angle  of  the  mouth  back  to  the  masseter  (Fig. 
324).  If  the  access  gained  is  still  insufficient,  and  particularly  if  infiltrated 
glands  are  present  in  the  neck,  the  incision  should  be  carried  across  the  angle 
of  the  jaw  and  thence  curved  so  as  to  pass  down  the  anterior  margin  of  the 
.  sternomastoid,  and  the  jaw  divided  at  the  level  of  the  last  molar  (L  a  n  g  e  n  - 
beck).  The  anterior  portion  of  the  jaw  is  retracted  firmly  forward  and 
the  posterior  portion  is  retracted  outward,  as  wide  a  gap  as  possible  being 
made  between  the  two  portions.  After  the  removal  of  the  involved-  glands, 
the  tongue  itself,  and  the  surrounding  implicated  structures,  the  divided  jaw 
is  wired  together. 

In  some  cases  of  extensive  involvement  it  may  be  advisable  to  dissect  out 
the  glands,  and  as  much  as  possible  of  the  branches  of  the  external  carotid 
artery  on  each  side,  and  then  to  dissect  out  the  tongue  and  adjacent  diseased 
structures  at  a  subsequent  operation. 


Fig.  324. — Splitting  the  Cheek  for  Extirpation  of 
THE  Tongue. 


554 


THE    SURGERY    OF    THE    HEAD 


Kocher's  Method. — The  advantages  of  this  method  are  (1)  it  gives  ready 
access  to  the  parts;  (2)  it  permits  simultaneous  removal  of  aU  of  the  tissues 
in  the  floor  of  the  mouth  and  the  glands  as  well;  (3)  it  permits  preliminary 
ligation  of  the  lingual  and  of  the  external  carotid  artery  when  necessary;  (4) 
the  pharynx  can  be  plugged  after  preliminary  tracheotomy,  this,  together  with 
the  efficient  drainage  which  can  be  obtained,  constituting  a  safeguard  against 
septic  bronchitis  and  pneumonia. 

A  preliminary  tracheotomy  is  performed,  and  the  chloroform  thereafter 
given  through  the  Trendelenburg  cannula  (Fig.  311).  Or  C  r  i  1  e  '  s 
method  of  administering  chloroform  through  nasal  tubes  and  tamponing  the 
pharynx  may  be  employed.  The  incision  commences  just  below  the  lobe  of 
the  ear,  extends  along  the  anterior  border  of  the  sternomastoid  to  the  middle 

of  the  latter;  thence  to  the  mid- 
dle line  of  the  neck  and  finally 
upward  to  the  border  of  the 
lower  jaw  (Fig.  325).  The  flap 
is  dissected  up  and  kept  well 
retracted  by  being  sutured  to 
the  cheek.  All  glands  beneath 
the  upper  portion  of  the  sterno- 
mastoid and  under  the  angle  and 
body  of  the  jaw  are  removed. 
The  anterior  border  of  the  sterno- 
mastoid is  bared  to  the  sheath 
of  the  large  vessels,  and  the 
greater  cornu  of  the  hyoicl  bone 
and  the  anterior  belly  of  the  di- 
gastric laid  bare.  The  mass  of 
glands  is  now  raised  and  the 
posterior  belly  of  the  digastric 
and  the  stylohyoid  exposed  in 
the  posterior  and  lower  portion 
of  the  wound.  The  submaxil- 
lary salivary  gland  is  dissected 
up  as  far  as  the  border  of  the 
jaw  and  removed  with  the  lym- 
phatic glands.  The  facial  vessels 
are  hgated  while  the  submaxillary  gland  is  drawn  upward;  the  lingual  artery 
is  ligated  as  it  passes  beneath  the  hyoglossus  muscle.  The  mylohyoid  muscle 
and  its  mucous  membrane  covering  are  cut  through  close  to  the  bone  and  the 
tongue  drawn  out  through  the  opening.  The  attachments  of  the  tongue  to 
the  hyoid  bone  are  now  separated,  together  with  all  infiltrated  tissues.  If 
the  entire  tongue  is  to  be  removed,  the  opposite  lingual  artery  is  to  be  ligated 
through  a  separate  incision  (see  Ligation  of  the  Lingual  Artery,  page.  558). 

If  the  carcinomatous  infiltration  involves  the  pharyngeal  walls,  these  can  be 

reached  through  the  same  opening.     The  periosteum  in  front  of  the  masseter 

and  pterygoid  muscles  is  detached  from  the  jaw,  the  bone  sawed  through  and 

drawn  well  forward,  in  order  to  gain  more  room.     The  bone  is  afterward  wired. 

The  wound  is  left  open  for  drainage.     The  Trendelenburg  tube  is 


Fig.  325. — Line  of  Incision  fob  Kocher's  Operation 
FOR  Cancer  of  the  Tongue. 
A  second  incision  may  be  carried  in  the  direction  of 
the   dotted  line    to    facilitate   the  removal   of  infected 
glands. 


THE    TOXGUE  555 

replaced  by  an  ordinary  tracheal  cannula  wliich  is  worn  until  the  A\'Ound  is  well 
granulated.  The  pharynx  is  packed  with  zinc  oxid  gauze  and  the  patient  fed 
with  a  tube  at  each  change  of  dressing,  at  which  time  also  the  parts  are  cleansed 
with  hydrogen  peroxid  and  irrigated  with  permanganate  of  potassium  solution. 

Nonmalignant  Tumors  of  the  Tongue.— These  occur  very  infrequently, 
as  compared  with  malignant  growths.  Tumors  of  embryonic  origin  resem- 
bling sacrococc3^geal  and  similar  tumors  are  sometimes  fomid  in  the  tongue. 

Lipomas. — These  are  usualh-  single,  situated  on  the  border  or  tip,  or  on 
the  dorsal  aspect,  with  the  overlying  mucous  membrane  smooth.  They  are 
of  slow  growth  and  produce  but  slight  inconvenience  except  when  they  attain 
sufficient  size  to  be  caught  between  the  teeth.  "Wlien  occurring  in  the  depth  of 
the  substance  of  the  tongue,  they  may  protrude  beneath  the  latter;  the  golden 
yellow  color  shining  through  the  mucous  mcmljrane  serves  to  distinguish  it 
from  so-called  ranula.      Multiple  and  diffuse  lipomas  have  also  been  observed. 

Fibromas. — These  are  observed  most  frequently  on  the  dorsum  and  may 
occur  as  multiple  growths,  with  varying  distances  between  the  growths.  They 
commence  in  the  substance  of  the  tongue,  but  finally  project  from  the  surface 
after  assuming  a  polypoid  form  (fibrous  polypi  of  the  tongue) .  They  resemble 
fatty  tumors  in  this  region,  except  that  the}-  lack  the  yellowish  hue  peculiar 
to  lipomas.  They  become  irksome  in  the  course  of  time  from  interference 
with  speaking  and  eating. 

Fibromyomas  and  rhabdomyomas  occur  as  circumscribed  growths  in  the 
substance  of  the  tongue.  The  latter  are  non-encapsulated,  and  may  attain 
the  size  of  a  pigeon's  egg.  In  consistency  and  color  they  resemble  the  normal 
structure  of  the  tongue. 

Cartilaginous  and  osseous  tumors  occur  either  as  congenital  chondromas 
and  osteomas,  or  develop  after  birth  as  mixed  tumors  containing  cartilage, 
bone,  fibrous  tissue,  and  fat. 

Amyloid  tumors  are  non-encapsulated  am}-loid  masses  occurring  at  the 
base  of  the  tongue  in  patients  d}ing  of  diseases  in  which  amyloid  degeneration 
occurs.  Cartilaginous  and  bony  nodules  are  sometimes  found  in  the  waxy 
substance. 

The  treatment  of  the  foregoing  consists  of  the  enucleation  through  a  single 
incision  of  those  growths  which  are  deeply  situated.  Polypoid  growths  are 
removed  simply  by  cutting  through  the  pedicle.  ]\Iultiple  and  diffuse  lipomas 
occurring  in  elderly  individuals,  and  giving  rise  to  no  special  inconvenience, 
should  not  be  interfered  with. 

Angiomas. — These  occur  on  the  tongue  in  the  same  forms  as  elsewhere, 
the  varieties  including  (1)  arteriovenous  aneurism;  (2)  aneurism  by  anas- 
tomosis or  cirsoid  aneurism ;  (3)  capillary  nevi ;  (4)  venous  nevi. 

Arteriovenous  aneurism  may  result  from  a  wound  and  is  recognized  by 
its  pulsation  and  thrill. 

In  aneurism  by  anastomosis  the  tumor  is  more  or  less  definitely  circum- 
scribed and  the  vessels  possess  a  distinct  wall.  The  growth  may  occupy  the 
front  half  or  one  of  the  lateral  halves  of  the  tongue  (Fig.  326)  or  appear  in  the 
situation  of  a  ranula.  The  tumor  may  be  emptied  by  pressure,  but  it  refills 
when  the  pressure  is  relieved.  Pulsation  is  more  or  less  marked.  Hemorrhage 
does  not  usually  occur. 

Capillary  nevi  may  be  congenital  or  acquired.     When  congenital,  they 


556 


THE    SURGERY    OF    THE    HEAD 


Fig.  326. — Cirsoid  Aneurism  of  Toxgue  of 
Twenty  Years'  Standing  in  a  Woman 
Forty  Years  of  Age. 


are  often  multiple  and  occur  on  other  parts  of  the  body  as  well  as  on  the  tongue. 

They  may  be  continued  into  the  mouth  as  a  simple  port  wine  stain  on  the  face. 

In  the  acquired  form  the}^  have  been  ob- 
served in  pregnant  women  and  in  others 
also.  The}'  appear  as  bright  red  tumors 
varying  in  size  from  a  pin's  head  to  a 
split  pea.  Arterial  hemorrhage  occurs, 
especially  on  eating. 

Venous  Nevi  (Cavernous  Tumors). 
— ^'enous  angiomas  are,  as  a  rule,  congen- 
ital. They  may  be  single  or  multiple, 
and  are  generally  situated  on  the  dorsum 
of  the  organ  in  the  anterior  half.  They 
project  slightly  and  their  dull  bluish  or 
hvid  color  shows  through  the  thinned 
mucous  membrane;  small  varicose  vessels 
and  vascular  areas  appear  on  the  mucous 
membrane.  This  variety  of  angioma  sel- 
dom attains  a  large  size,  is  painless,  as  a 
nile,  and  does  not  usually  give  rise  to 
great  inconvenience.  Profuse  hemor- 
rhage may  occur  from  accidental  injur}'. 
Lymphangiomas     may    begin    T\dth 

what  appears  to  be  a  simple  ne^iis;  with  the  steady  advance  of  the  l}-mphan- 

gioma  marked  macroglossia  may  ensue. 
Lingual  angiomas,  like  similar  vas- 
cular tumors  elsewhere,  occasionally  be- 
come parti}'  obliterated  by  fatty  degen- 
eration. 

The  diagnosis  of   angiomas  of  the 

tongue   is  made  on  the  same  basis   as 

vascular  tumors  in  general,  namely,  the 

color,  consistency,  diminution  in  size  on 

pressure,  and  rapidity  of  return  to  their 

original  dimensions  when  the  pressure  is 

relieved.      An    arteriovenous     aneurism 

may  give  a   histor}'  of   an   injur}';    the 

presence  of  a  thrill  is  characteristic.     In 

cirsoid  aneurism   large   tortuous  A'essels 

are   present.     Capillar}-  nevi  of  congen- 
ital  origin  are  similar  to   the   common 

"birthmark"  seen  on  the  skin.    Accjuired 

capillary  nevi  exhibit  a  tendency  to  bleed, 

particularly  in  the  case  of  women  during 

pregnancy.     Venous  cavernous  nevi  are 

usually  situated  on  the  anterior  half  of 

the  tongue;   small  varicose  vessels  and  vascular  spots  are  obser^-ed  on  the 

mucous  membrane  covering  the  nevus. 

Treatment  of  Angiomas  of  the  Tongue. — In  cases  showing  a  tendency 


Fig.     327. — Cirsoid     Aneurism     of    the 
Tongue. 
Showing  swelling  in  the    neck  when  the 
tongue  is   retracted   into    the   cavity  of   the 
mouth. 


THE   TONGUE  557 

to  progressi^'e  growth  early  operation  is  indicated.  Small  nevi  may  be  de- 
stroyed with  the  galvanocautery  or  thermocauter}-;  two  or  three  applica- 
tions may  be  needed.  The  hemorrhage  is  slight  if  a  dull  red  heat  only  is 
employed.  Removal  en  masse  by  means  of  an  elastic  or  other  ligature  is 
liable  to  be  followed  by  septic  pneumonia.  Excision  of  a  wedge-shaped 
piece,  the  incision  passing  beyond  the  vascular  area,  is  the  operation  of  choice. 
The  vessels  can  be  usually  secured  in  the  healthy  tissues  and  oozing  arrested 
by  deep  suturing.  The  cut  surfaces  may  be  touched  with  the  cauter}'  or  the 
entire  excision  ma}-  be  performed  Avith  the  latter.  In  large  and  diffuse  caver- 
nous tumors,  cirsoid  aneurism,  and  arteriovenous  aneurism  electrolysis  at 
several  sittings  may  be  tried.  Preliminary  ligation  of  the  Unguals  should  be 
practised  before  either  electrolysis  or  excision  in  this  class  of  cases. 

Papillomas  are  among  the  most  common  nonmalignant  tumors  of  the 
tongue.  They  are  not  limited  to  the  papillar}^  area  of  the  organ,  but  are  some- 
times found  on  the  under  surface.  The  entire  fungiform  papillae  of  the  tongue 
may  become  inA'olved  in  a  warty  enlargement.  A  peculiar  form  of  sublingual 
growth,  the  product  of  an  inflammatory  process  due  to  irritation,  is  kno\\-n 
as  Riga's  disease.  It  occurs  on  either  side  of  the  frenum  in  young  children 
from  contact  with  the  sharp  incisor  teeth.     The  treatment  is  by  excision. 

Sessile  warty  growths  which  form  on  patches  of  leukoplakia  commence 
as  an  apparent  thickening  of  the  surface  of  the  latter.  Later  on  they  assume 
a  more  decidedly  warty  character,  and  finally,  if  left  untreated,  become  in- 
durated about  the  base,  a  condition  indicating  the  cancerous  nature  of  the 
affection  in  this  stage  of  its  development. 

In  the  diagnosis  of  papillomas  care  should  be  taken  to  differentiate  the 
disease  from  warty  s}'philitic  growths,  or  condylomas,  particularly  in  children 
and  young  adults.  A  10  grain  to  the  ounce  solution  of  chromic  acid  causes  a 
syphilitic  gro'U'th  to  disappear  rapidly,  while  a  true  papillary  growth  is 
unaffected  by  the  application.  If  accompanied  by  chronic  superficial  glossitis 
in  a  male  between  thirty  and  sixty,  the  differential  diagnosis  from  epitheliomas 
is  not  so  eas}-.  The  presence  of  ulceration,  and  of  induration  about  the  base, 
is  of  importance  as  showing  the  presence  of  malignant  disease.  If  the  latter 
has  indubitably  supervened,  the  microscope  will  aid  in  the  differentiation. 

The  treatment  of  papillomas  consists  in  their  early  removal,  particularly 
in  persons  over  thirt}'.  The  base  should  be  included  in  two  elliptic  incisions 
extended  deeply  into  the  substance  of  the  tongue  and  the  growth  removed 
with  some  of  the  adjoining  healthy  tissue.  The  gap  left  is  closed  by  sutures. 
If  ulceration  and  an  indurated  base  are  present,  the  operation  should  be  as 
if  for  epitheliomas,  even  if  the  microscopic. examination  is  negative,  since  the 
latter  may  fail  to  discover  the  difference  in  the  period  of  transition  from  a 
-benign  to  a  malignant  growth.  Caustics  should  never  be  used  on  these  growths. 
Destruction  l^y  means  of  the  galvanocautery  is  inferior  to  excision. 

Hypertrophy  of  the  Blandin-Nuhn  gland  beneath  the  tip  of  the  tongue 
has  been  occasionally  observed. 

Ligation  in  Continuity  of  the  Lingual  Artery. — A  cushion  or  block 
is  placed  beneath  the  patient's  shoulders  and  the  head  turned  slightly 
toward  the  opposite  side.  The  incision  is  commenced  slightly  to  the  outer 
side  of  the  sympliA'sis  menti  and  about  j  of  an  inch  above  the  body  of  the  hyoid 
bone.     With  its  convexitv  downward  it  is  carried  for  about  two  inches  along 


558 


THE    SURGERY    OF   THE    HEAD 


the  border  of  the  jaw,  reaching  to  a  point  just  in  front  of  where  the  facial 
artery  crosses  the  latter.  Its  center  is  just  above  the  greater  cornu  of  the 
h}'oid  bone.  After  separation  of  the  skin,  platysma,  and  superficial  fascia, 
the  subniaxillarv  gland  comes  into  view.  This  is  to  he  separated  from  its 
surrounding  connective-tissue  attachments  and  retracted  upward,  the  lower 
edge  of  the  incision  being  retracted  downward  at  the  same  time  (Fig.  328). 
The  two  bellies  of  the  digastric  muscle  now  come  into  view.  The  hypoglossal 
nerve  and  ranine  vein  are  exposed  by  depressing  the  digastric  at  the  point 
where  its  two  bellies  meet,  with  a  blunt  tenaculum.     By  retracting  the  nerve 


Fig.  328. — Ligation  of  Lingual  Artery,  showing  Hueteh's  Triangle. 

and  vein  in  an  upward  direction  the  trigonum  linguale  (H  u  e  t  e  r)  is  formed. 
The  artery  lies  at  the  lower  portion  of  this  triangle,  beneath  the  thin  hypo- 
glossus,  which  muscle  is  divided  in  a  horizontal  direction.  At  this  point  the 
vessel  changes  its  direction  from  the  horizontal  and  assumes  a  vertical  course 
to  enter  the  tongue;    it  is  usually  accompanied  by  a  small  vein. 

The  operation  is  performed  most  frequently  for  disease  of  the  tongue, 
preliminarily  in  complete  extirpation  for  carcinoma,  or  to  restrict  the  circu- 
lation and  thus  limit  the  nutrition  of  diseased  portions  of  the  organs,  as,  for 
instance,  in  hemihypertrophy. 


THE  SOFT  AND  HARD  PALATE 

THE   VELUM 

Wounds  of  the  soft  palate  are  not  usually  followed  by  septic  inflamma- 
tory processes.  Cicatrization  of  wounds  of  the  velum  sometimes  leads  to 
interference  with  speech,  and  whenever  possible  primary  union  should  be 
secured  by  suturing.     Foreign  bodies  are  usually  removed  without  difficulty. 

Primary  inflammation  of  the  soft  palate  is  not  common,  but  it  usually 


THE    SOFT    AND    HARD    PALATE 


559 


Fig.  329. — Whitehead's  Gag. 


takos  moro  or  loss  part  in  that  arising;  in  the  adjacent  parts.  Phlegmonous 
inflammation  in  the  peritonsillar  connective  tissue  (quinsy),  as  well  as  diph- 
theria of  the  tonsils  and 
pharynx,  may  extend  to 
the  soft  palate.  Syphil- 
itic ulceration  may 
occur,  and,  by  cicatriza- 
tion, necessitate  a  subse- 
(juent  plastic  operation. 
The  uvula  may  become 
the  seat  of  edematous 
swelling  from  slight 
causes  and  be  considera- 
bly lengthened. 

Fissures  of  the  Soft 
Palate. — C  on  g  en  i  t  a  1 
fissure  of  the  soft  palate 

constitutes  one  of  the  forms  of  cleft  palate.  It  occurs  almost  exclusively 
in  the  median  line.  The  uvula  is  usually  involved  in  the  fissure.  The 
margins  of  the  fissure,  A^'hen  com- 
plete, terminate  at  an  acute  angle 
at  the  posterior  edge  of  the  hard 
palate;  the  latter  may  be  invaded 
for  a  short  distance.  Incomplete 
fissure  extends  only  a  part  of  the 
way;  the  uvula  alone  may  be  in- 
volved (bifid  uvula). 

Acquired  Cleft  of  the  Soft 
Palate. — Unhealed  wounds  of  the 
soft  palate  may  result  in  a  cleft, 
this  varying  in  form  and  extent. 
This  condition  is  also  due  to  con- 
stitutional syphilis,  and  presents. 


Fig.  330. — Brophy's  Mouth  Speculum. 


Fig.  331. — Brophv's  Mouth  Speculum  Applied. 
Patient  in  the  dependent  head  position  of  Rose. 


under  these  circumstances,  the  rather  constant  and  characteristic  form  of  an 
oval  or  oblong  shape  due  to  the  fusion  of  several  openings  resulting  from 
gummatous  infiltration,  with  varying  degrees  of  destruction.     The  ulceration 


560 


THE    SURGERY    OF   THE    HEAD 


frequently  extends  from  the  posterior  surface  of  the  ^-ehim  to  the  adjacent 
pharyngeal  walls;  fusion  occurs  and  the  margins  of  the  remains  of  the  soft 
palate  are  dragged  to  each  side,  greatly  enlarging  the  fissure.  Disturbances 
of  speech  and  deglutition  are  marked. 


Fig.  332. — Cheek  Retractor. 


The  treatment  of  congenital  cleft  of  the  soft  palate  is  by  staphylorrhaphy. 
Acquired  clefts  of  traumatic  origin  may  be  similarly  treated  where  there  is 
not  great  loss  of  substance.  Those  due  to  syphilitic  infection  are  best  treated 
by  an   obturator  or  artificial   velum   (K  i  n  g  s  1  e  y  ,   Suersen). 

Operation  of  Staphylorrhaphy. — The  operation  is  divided  into  (1)  paring 
the  margins;  (2)  dividing  the  muscles  to  relieve  tension;  (3)  introducing 
the  sutures. 


Fig.  333. — Staphylorrhaphy.     Paring  the  Edges. 

Paring  the  Margins. — A  suitable  gag  or  mouth  speculum  is  introduced 
(Figs.  329  and  330).  A  cheek  retractor  is  of  service  (Fig.  332).  The  dependent 
head  po.sition  of  Rose  is  the  best  (Fig.  331).  One  edge  of  the  fissure 
is  grasped  by  a  tenaculum  or  mouse-toothed  forceps  and  a  thin  and  narrow- 


THE    SOFT   AND    HARD   TALATE 


561 


bladed  bistoury  is  passed  throii2;h  just  in  front  of  the  angle  and  at  a  little 
distance  from  the  margin.     By  gcntlv  sawiu";  movements  the  incision  thus 


Fig.  334. — Staphylorrhaphy  Scissors  for  Dividixg  the  Levatores  Pal.^ti. 


commenced  is  carried  parallel  to  the  margin  until  tlie  tip  of  the  uvula  is  reached 
(Fig.  333).     This  is  repeated  on  the  other  side.     The  two  incisions  are  then 
united  at  tlie  bottom  of  the  angle  b_y  a  curved  cut  made  by 
a    sweeping  movement  of   the  knife,  the   paring  being  re- 
moved in  one  piece. 

Dividing  the  Muscles. — If  this  is  done  before  intro- 
duction of  the  sutures,  a  sickel-shaped  knife  (L  a  n  g  e  n- 
beck's)  is  passed  through  the  cleft,  its  point  introduced 
over  the  hamular  process,  which  can  be  felt  b}'  the  point 
of  tlie  finger  in  close  relation  to  tlie  last  upper  molar,  and 
the  section  made  while  the  corresponding  portion  of  the 
velum  is  made  tense.  Or,  the  double  curved  scissors  may 
be  employed  for  this  purpose  (Fig.  334).  These  incisions 
divide  tlie  levatores  palati.  If  tension  still  exists,  the  pala- 
topharvngei  may  be  di^'ided 
simply  by  cutting  across  the 
posterior  pillars  with  blunt 
scissors. 

Introducing     the      Su- 
tures.— A      small      half-circle 
needle    grasped    by    a   needle 
holder    serves    best,    when    it 
can   be    emplo^'ed.     A   needle 
with  the  eye  at  the  point  ma}' 
be  passed  armed  with  a  ''car- 
rier,"  i.   e.,   a   double    thread 
(Fig.  335),  the  "bight '  or  loop      Fig. 
of  which  is  left  in  the  gap.     A 
single  thread  is  then  introduced 
from  the  other  side,  its  free  end   passed  through  the  carrier  and   the  latter 
withdrawn,  carrying  with  it  the  single  thread  which  is  to  remain  as  a  suture 
(Fig.  336).     An  ordinary  needle,  if  small  and  well  curved,  may  be  employed 
when  armed  with  a  carrier.     A  good  quality  of  silk  is  the  best  suture  material. 


Fig.  335. — Needle 
Armed  with  Car- 
rier. 


336. — Passing  the  Sutures 
IX  Staphylorrhaphy  (Dia- 
gram.matic). 


THE  HARD  PALATE 

Slight  injuries  of  the  mucous  membrane  covering  the  hard  palate  arising 
from  foreign  bodies  in  the  food  are  unimportant.     Those  which  involve  the 
37 


562  THE  SURGERY  OF  THE  HEAD 

entire  thickness,  as,  for  instance,  when  they  are  caused  by  the  fall  of  a  child 
with  a  pencil  or  toy  in  its  mouth,  or  perforation  occurs  by  a  pistol  ball,  are 
of  greater  importance.  \^Tien  the  latter  in\olves  a  suicidal  attempt,  there  is 
accompanying  extensive  contusion  of  the  surrounding  soft  parts. 

Suppuration  of  the  antrum  of  Highmore  may  follow  the  last  named  injury. 
There  may  be  some  limited  necrosis,  but  the  sequestra  easily  separate  and 
the  opening  finally  closes.  Extensive  destruction  of  bone  may  lead  to  a  per- 
manent communication  between  the  cavity  of  the  mouth  and  the  nasal  cavity 
in  case  of  median  situation  of  the  opening,  and  between  the  cavity  of  the 
mouth  and  the  antrum  of  Highmore  in  case  of  lateral  situation. 

Suppurative  periostitis  occurs  as  an  extension  of  a  similar  condi- 
tion from  the  alveolar  processes  in  phosphorus  poisoning.  When  sequestra 
are  separated  they  should  be  removed  from  the  direction  of  the  gums,  but 
not  by  an  incision  in  the  median  line,  lest  a  permanent  opening  be  left  in  the 
roof  of  the  mouth  communicating  vrith  the  nasal  fossa.  The  exfoliated  por- 
tions are  usually  replaced  by  new  bone  formation.  Syphilis  of  the  palate 
appears  almost  exclusively  in  the  shape  of  gummas,  the  nodule  of  which  is 
strictly  limited  to  the  median  line  or  raphe  of  the  palate  wliere  the  two  palatal 
processes  of  the  superior  maxillary  bone  join  the  septum.  A  bony  ridge 
marks  the  site  of  the  syphilitic  infiltration  if  the  diseased  condition  is  arrested 
by  appropriate  treatment.  Otherwise  the  entire  thickness  of  the  bone  becomes 
affected,  more  or  less  of  the  bony  vault  is  destroyed,  and  with  the  final 
cicatrization  small  or  large  openings  are  left.  These  may  be  distinguished 
from  those  due  to  injury  by  the  fact  that  they  are  situated  in  the  median 
line  and  are  oblong  in  shape,  while  those  from  injury  vary  in  situation  and 
are  usually  round. 

Congenital  Cleft  of  the  Hard  Palate. — This  may  be  partial  or  com- 
plete. It  is  always  associated  with  cleft  of  the  soft  palate.  The  cleft  may 
pass  to  one  side  of  the  vomer;  more  commonly,  how^ever,  it  passes  directly  in 
the  median  line,  leaving  the  palatal  edge  of  the  vomer  free.  It  is  frequently, 
though  not  invariably,  associated  with  harelip.  The  latter  may  be  single  or 
double.  In  complete  cleft  of  the  hard  palate  the  fissure  is  V-shaped,  with  the 
opening  of  the  angle  posteriorly  situated,  and  with  the  anterior  portion  and 
the  alveolar  processes  intact.  In  complete  cleft  the  fissure  passes  to  the 
alveolar  processes  in  front  and  in  some  instances  involves  it.  The  latter  con- 
dition alwaj^s  obtains  when  double  harelip  is  present,  on  account  of  the  for- 
ward displacement  of  the  premaxillary  bone. 

The  functional  disturbances  in  the  newborn  resulting  from  cleft  palate 
relate  principally  to  interference  with  suckling.  As  a  rule,  the  infant  will 
require  to  be  artificially  fed.  A  feeding  bottle  with,  a  large  nipple  to  close 
the  gap,  or  a  specially  constructed  nipple  with  a  rubber  shield,  may  be  used. 
Malnutrition  is  not  uncommonly  present  in  spite  of  these  appliances. 

Defects  in  speech  in  older  children  are  next  in  importance.  As  the  child 
learns  to  talk  it  will  be  found  that  these  are  present,  generally  speaking,  in 
proportion  to  the  extent  of  the  cleft.  In  cases  uncomplicated  by  harelip  labial 
sounds  are  usually  enunciated  without  difficulty;  those  requiring  pressure  of 
the  tongue  against  the  hard  palate  and  of  the  velum  against  the  posterior 
phar^mgeal  wall  are  lost.  Even  under  the  most  favorable  conditions  of  a  short 
cleft  the  impairment  of  speech,  consisting  of  a  broad  nasal  sound,  is  noticeable. 


THE    SOFT    AXD    HARD    TALATE  563 

Unfortunately,  in  the  majority  of  cases  the  habits  of  speech  first  formed  cUng 
to  the  patient,  even  after  the  most  successful  operative  closure,  or  the  applica- 
tion of  an  obturator  and  artificial  soft  palate.  The  continued  impairment  is 
due  in  part  to  absence  of  development  of  the  levator  palati  and  palatophar\-n- 
geal  muscles,  and  in  part  to  early  acciuired  habits  of  speech.  These  are  more 
difficult  to  overcome  after  operative  closure  than  in  case  of  application  of  an 
obturator  and  artificial  soft  palate,  for  the  reason  that  division  of  the  muscles 
to  relieve  tension  on  the  approximated  edges  of  the  cleft  in  the  soft  palate  is 
usually  necessary,  this  involving  permanent  impairment  of  these  to  a  greater 
or  lesser  extent.  When  an  obturator  and  artificial  velum  are  properly  fitted, 
the  muscular  apparatus  of  the  soft  palate  is  brought  into  use.  With  careful 
training  by  means  of  selected  vocal  exercises  the  muscles  develop,  and  at  the 
same  time  faulty  habits  of  speech  are  corrected. 

The  lodgment  of  particles  of  food  in  the  nasal  cavities,  leading  to  catarrhal 
inflammation  of  these,  constitutes  a  further  indication  for  operative  correction 
of  the  defect,  or  the  application  of  a  proper  prosthetic  apparatus. 

Treatment. — Opinions  differ  as  to  the  age  at  which  operative  measures 
should  be  instituted  for  cleft  palate.  In  view  of  the  fact  that  faulty  habits 
of  speech,  once  acquired,  are  very  difficult  to  overcome,  Wolff,  of  Berlin, 
advised  operative  interference  in  early  infancy.  His  method  was  to  loosen 
by  means  of  the  chisel  the  remains  of  the  hard  palate  adjoining  the  alveolar 
processes,  and  to  force  these  toward  the  median  line  until  the  previoush- 
freshened  margins  of  the  cleft  palate  came  into  apposition  (osteoplastic 
closure).  The  gaps  left  by  this  median  displacement  of  the  lateral  portions  of 
the  hard  palate  were  left  to  heal  by  granulation.  The  cleft  in  the  soft  palate 
was  closed  by  the  usual  staphylorrhaphy  (see  page  560).  By  operating  in  this 
manner  before  the  child  learned  to  talk,  it  was  thought  that  one  of  the  causes 
of  permanently  defective  speech,  namely,  habit,  would  be  overcome.  In  order 
to  avoid  the  necessity  for  di\asion  of  the  muscles.  howe\'er,  operation  in  the 
earliest  period  of  the  infant's  life  is  demanded.  It  is  surprising  to  what  an 
extent  the  muscles  attached  to  the  soft  palate  make  tension  upon  and  separate 
the  edges  of  the  cleft  in  this  region  during  the  act  of  crying,  even  in  an  infant 
only  a  tew  weeks  old. 

If  this  eariier  period  of  life  is  chosen  for  operation,  however,  the  latter  must 
necessarily  involve  a  liigher  mortality,  since  very  3'oung  infants  succumb 
more  easily  to  the  combined  effects  of  shock  ancl  loss  of  blood  than  those 
farther  advanced.  This  consideration  is  somewhat  compensated  for  by  the  fact 
that  the  operation  may  be  performed  on  the  former  without  the  administra- 
tion of  an  anesthetic. 

The  method  of  osteoplastic  closure  of  the  cleft  by  forcing  together  both 
the  lateral  portions  of  the  hard  palate  and  the  alveolar  processes  (B  r  o  p  h  y), 
the  gaps  left  by  section  of  the  former  being  thus  avoided,  succeeded  the  method 
of  Wolff.  This  can  be  done  -v^ith  comparative  ease  in  ver\-  young  infants. 
The  resulting  narro^\-ing  of  the  face  disappears  in  time.  The  edges  of  the  cleft 
are  first  carefully  freshened  in  their  entire  extent.  The  superior  maxillas  are 
perforated  on  each  side  just  above  the  alveolar  processes  at  the  gingivobuccal 
fold  and  two  stay  wires  of  silver  passed  above  the  plane  of  the  cleft.  The 
ends  of  these  are  passed  through  carefully  fitted  lead  plates  placed  between 
the  cheek  and  the  gum.     The  maxillas  are  now  forced  together,  the  special 


564 


THE    SURGERY    OF    THE    HEAD 


compression  forceps  of  h  r  o  p  h  y  or  other  mechanical  means  being  employed 
if  necessary.  If  the  bone  does  not  yield  readih-,  it  may  be  weakened  just 
above  the  level  of  the  stay  sutures  by  one  or  more  short  incisions  with  a  stout 
scalpel.  When  approximation  is  secured  the  raw  edges  of  the  cleft  are  imited 
by  a  row  of  fine  silk  sutures. 

]\Iore  or  less  blood  may  be  swallowed  b\'  the  ])atient  during  the  operation, 
and  the  fever  following  the  digestive  disturbances  and  absorption  may  inter- 
fere with  the  healing  process.  Every  care  should  be  taken,  therefore,  to  a^-oid 
the  swallowing  of  blood  by  keeping  the  parts  carefull}^  sponged  and  the 
phar\'nx  clear.  The  administration  of  an  emetic,  followed  by  a  simple 
purge,  is  an  additional  safeguard  against  failure  from  this  cause.  Occasional 
cleansing  of  the  mouth  with  a  boric  acid  solution,  particularh"  after  food  has 
been  taken,  should  be  practised. 

The  operation  of  uranoplasty,  as  applied  to  older  children  and  adults, 
is  performed  as  follows:  The  mouth  is  carefully  cleansed,  ether  administered, 
and  the  patient  placed  in  the  dependent  head  position  of  R  o  s  e  (Fig.  331). 

After  the  patient  is  fully 
anesthetized  the  administra- 
tion of  the  ether  is  carried 
on  through  the  Junker 
inhaler  (Fig.  323).  A  .suture 
is  passed  transversely 
through  the  dorsum  of  the 
tongue  behind  the  frenum 
and  given  in  charge  of  an 
assistant.  The  largest  sized 
combined  oral  speculum  and 
tongue  depressor  (Fig.  330) 
that  the  oral  opening  will 
accommodate  is  introduced. 
Or  the  rack-and-pinion 
mouth-gag  may  be  employed 
(Fig.  337).  The  edges^  of 
the  cleft  are  carefully  freshened,  as  in  staphylorrhaphy  (Fig.  333).  The 
mucoperiosteal  coverings  of  the  hard  palate  are  now  thoroughly  separated 
from  the  bone  in  all  directions  by  means  of  the  raspatory  (Fig.  338).  In 
carrj-ing  out  this  step  of  the  operation  care  should  be  exercised  not  to  contuse 
the  freshened  edges  of  the  soft  parts  of  the  cleft.  The  elevator  should  be  kept 
close  to  the  bone  and  the  process  continued  until  the  entire  hard  palate  is 
denuded. 

A  traction  suture  is  now  passed  througli  the  velum  on  each  side  and  each 
half  drawTi  strongly  forward  and  toward  the  opposite  side,  while  the  finger 
palpates  the  site  of  the  levator  palati  and  palatophaiyngeal  muscles  of  the 
corresponding  side  to  determine  the  amount  of  tension  ])resent.  Usually  these 
^\ill  recjuire  division  (see  Staphylorrhaphy,  page  560).  The  fact  that  these 
have  been  thoroughly  divided  will  be  determined  by  the  palpating  finger. 

The  ability  to  approximate  the  edges  of  the  mucoperiosteal  flaps  is  now 
tested.  In  cases  in  which  a  high  arch  or  vault  exists  the  edges  will  fall  to- 
gether easily.     In  a  low  or  flat  vault  the  edges  will  fail  to  approximate,  and 


Fig.  .337. — Rack-and-pixiox  Mouth-gag. 


THE    SOFT    AND    HARD    PALATE 


565 


a  relaxing  incision  parallel  to  the  alveolar  margin  on  each  side  must  be  made. 
These  incisions  must  not  be  made  longer  than  is  necessary  to  effect  approxi- 
mation, lest  the  blood-sii])ply  be  interfered  with  and  sloughing  of  the  flaps 
ensue. 

In  the  application  of  the  sutures  ])r()\ision  must  be  made  for  removing 
all  ])()ssil)le  strain  from  the  line  of  union.  The  relaxation  sutures  intended  to 
accomplish  this  are  of  sih'er  wire,  are  passed  through  the  flaps  about  half-way 
between  the  freshened  margin  and  the  edge  of  the  relaxation  incision  of  each 
side,  and  are  secured  b>'  being  passed  through  a  narrow  and  thin  lead  plate 
and  clamped  with  perforated  shot.  When  the  edges  have  been  accurately 
adjusted  by  means  of  the  relaxation  sutures  they  are  united  by  a  row  of  fine 
silk  sutures.     The  lateral  gaps  are  packed  with  sterile  gauze! 

In  order  to  prevent  the  child  from  reaching  the  line  of  sutures  and  separat- 
ing them  with  the  tip  of  the  tongue  the  latter  may  be  secured  by  a  suture  to 


Fig.  33S. — Raspatories  for  Uranoplasty. 

the  lower  gingivolabial  fold  for  the  first  few  days,  in  cases  in  which  the  lower 
front  teeth  are  absent.  Careful  antiseptic  cleansing  should  be  carried  out 
in  the  after-treatment.  The  palatal  sutures  may  be  removed  from  the  eighth 
to  the  tenth  day. 

The  Non-operative  Treatment  of  Cleft  Palate.— The  apphcation  of  a 
prosthetic  apparatus  involves  considerable  expense  and  is  beyond  the  reach 
of  poor  patients.  It  cannot  be  advantageously  applied  until  the  permanent 
teeth  have  erupted.  Constant  care  is  necessary  to  cleanse  the  apparatus 
properly  and  prevent  damage  to  the  teeth  to  which  it  is  attached.  The  latter 
should  be  regularly  inspected  by  a  competent  dentist.  To  offset  these  dis- 
advantages, it  may  be  said  that  the  functional  results  are  far  superior  to  those 
obtained  by  any  operative  procedure  performed  after  the  patient  has  learned 
to  talk,  provided  pains  are  taken  to  train  the  vocal  organs  properly  after  its. 
application. 


566  THE  SURGERY  OF  THE  HEAD 


THE  FAUCES,  PHARYNX,  AND  NASOPHARYNX 
THE  TONSILS 

The  tonsils  are  vestigial  structures,  endowed  with  a  low  power  of  vital 
resistance  and  with  numerous  recesses  which  invite  the  presence  of  agents 
of  infection.  For  these  reasons  they  are  very  Uable  to  become  the  seat  of 
inflammatory  processes. 

Acute  Tonsillitis. — This  occurs  m  connection  with  acute  catarrhal 
pharyngitis.  The  attack  may  resemble  erysipelas  of  the  skin;  in  fact,  facial 
erysipelas  may  be  accompanied  by  a  hyperacute  inflammation  of  the  mucous 
membrane  of  the  oral,  nasal,  and  phaiyngeal  cavities. 

Follicular  Tonsillitis. — This  may  follow  an  attack  of  acute  catar- 
rhal tonsillitis.  It  usually  pursues  a  chronic  course,  with  occasional 
acute  exacerbations.  The  tonsils  swell  considerably  and  project  from  be- 
tween the  faucial  pillars.  The  contents  of  the  crypts  accumulate  and  are 
either  removed  by  coughing  or  become  desiccated  and  form  concretions  (ton- 
sillar calculi).  Decomposition  of  the  accumulated  secretions  sometimes  gives 
rise  to  a  foul  breath. 

Hypertrophic  tonsillitis  results  from  either  acute  catarrhal  tonsillitis 
or  follicular  tonsillitis.  Repeated  attacks  of  the  former,  a  long  continuance 
of  the  latter,  or  a  mixture  or  alternation  of  the  two,  induce  connective-tissue 
hyperplasia  and  enlargement  of  the  tonsils  to  the  extent  of  a  tumor  as  large  as 
the  end  of  the  thumb  or  larger. 

Phlegmonous  tonsillitis  (peritonsillitis)  is  a  phlegmonous  inflamma- 
tion of  the  peritonsillar  connective  tissue.  The  connective  tissue  of  the 
tonsil  proper  is  composed  of  short  and  rigid  fibers  and  is  but  little  prone 
to  phlegmonous  inflammation.  The  infectious  agents  of  a  catarrhal  or  fol- 
licular tonsillitis  may  pass  to  the  connective  tissue  between  the  tonsil  and  the 
faucial  pillars  and  set  up  a  phlegmonous  suppurative  inflammation. 

Diphtheritic  Tonsillitis. — This  form  is  characterized  by  the  forma- 
tion of  a  pseudomeml^rane  on  the  surface.  The  false  membrane  consists  of 
layers  of  micrococci,  fibrinous  filaments,  pus  corpuscles,  and  epithelium.  The 
pellicles,  the  coalescence  of  which  makes  up  the  bulk  of  the  false  membrane, 
develop  first  in  the  depths  of  the  tonsillar  crypts  as  the  result  of  the  presence 
of  the  special  bacillus  of  the  disease  (K  1  e  b  s  -  L  5  f  f  1  e  r).  The  pres- 
ence of  this  bacillus  may  be  demonstrated  by  bacteriologic  examination  for 
diagnostic  purposes   (see  page  29). 

Ulcerative  conditions  of  the  tonsils  are  observed.  These  are  (1) 
syphilitic;  (2)  carcinomatous;  (3)  tuberculous;  (4)  lupous.  Those  due  to 
syphilis  extend  to  the  velum  and  pharyngeal  mucous  membrane;  those  of  a 
carcinomatous  nature  are  to  be  differentiated  by  the  microscopic  section; 
tuberculous  ulceration  is  usually  accompanied  by  general  tuberculosis,  in 
addition  to  which  the  bacillus  tuberculosis  may  be  found  by  microscopic  ex- 
amination. 

Symptoms. — Swallowing  is  greatly  embarrassed  in  phlegmonous  tonsillitis, 
rather  less  so  in  the  acute  catarrhal  form,  still  less  in  the  follicular  and  least 
of  all  in  the  hypertrophic  form.      Respiration  may  be  interfered  with,  notably 


THE   FAUCES,    PHARYNX,    AND    NASOPHARYNX  567 

in  the  phlegmonous  variety.  'Hie  infiannnutory  process  may  extend  to  the  mus- 
cular attachments  of  the  inferior  maxilla  and  produce  inflammatory  lock- 
jaw. 

Inspection,  in  the  acute  catarrhal  form,  shows  the  tonsil  to  be  evenly 
reddened  and  slightly  enlarged.  In  the  follicular  variety  yellowish-white 
spots  are  seen  in  the  crypts  of  the  swollen  organ;  slight  reddening  is  present. 
In  hypertrophic  tonsillitis  the  tonsils  project  like  tumors  from  between  the 
pillars  of  the  fauces,  the  latter,  however,  remaining  distmct.  The  tonsils 
may  be  so  large  as  to  come  in  contact  with  each  other  by  their  inner  surfaces. 
In  phlegmonous  tonsillitis  also  the  projection  is  considerable,  but  the  organ, 
instead  of  becoming  prominent  between  the  pillars  of  the  fauces,  as  in  the 
hypertrophic  form,  carries  the  palatoglossal  pillar  along  with  it  toward  the 
uvula.  In  the  latter  form  the  mucous  membrane  is  thickened,  intensely 
red,  and  covered  with  glairy  mucus.  In  diphtheritic  tonsillitis  the  false  mem- 
brane first  appears  as  a  grayish  veil  covering  the  tonsils  near  the  lower  infected 
crypts;  later  on,  this  assumes  a  characteristic  white  appearance. 

General  febrile  disturbance  occurs  in  acute  catarrhal  tonsillitis.  This, 
and  in  addition  enlargement  of  the  submaxillary  lymphatic  glands,  is  also 
present  in  both  phlegmonous  and   diphtheritic   tonsillitis. 

Disturbances  of  function  are  present  to  a  greater  or  lesser  degree  in  hyper- 
trophic tonsillitis.  There  is  a  nasal  sound  to  the  speech  from  rigidity  of 
the  velum  and  separation  of  the  nasal  cavity  from  the  pharyngeal  cavity. 
Impairment  of  hearing  may  result  from  occlusion  of  the  pharyngeal  orifice 
of  the  Eustachian  tube  either  by  the  swollen  tonsil  or  by  the  accessory  mflamma- 
tion  of  the  pharyngeal  mucous  membrane.  Mouth-breathing  may  become 
habitual ;  snoring  while  asleep  occurs  from  the  vibrations  in  the  tense  velum. 

Prognosis. — This  is  always  grave  in  diphtheritic  tonsillitis,  either  by  exten- 
sion to  the  pharynx,  larynx,  and  nasal  cavities,  or  by  general  infection. 
Phlegmonous  tonsillitis  may  cause  death  by  extending  along  the  planes  of  con- 
nective tissue  and  giving  rise  to  suppurative  pleuritis,  or  edema  of  the  glot- 
tis; finally,  suppurative  erosion  of  the  carotid  artery  and  fatal  hemorrhage 
may  occur.  Usually,  however,  the  focus  of  suppuration  points,  and  if  not 
incised  finally  breaks  through  the  thinned  mucous  membrane,  and  rapid 
recovery  ensues.     Recurrences  are  liable  to  take  place. 

Treatment. — Usually  only  the  phlegmonous  and  hypertrophic  forms 
come  under  the  surgeon's  care.  The  first  demands  early  incision,  this  being 
repeated  from  time  to  time  until  either  the  suppurating  focus  is  reached  or 
subsidence  of  the  inflammation  follows  the  antiphlogistic  effects  of  the  local 
depletion ;  the  relief  of  tension  and  diminution  of  pressure  bj^  division  of  the 
peritonsillar  structures  is  also  of  service,  even  though  no  pus  escapes.  Deep 
suppuration  will  sometimes  find  its  way  to  the  bottom  of  an  incision  and  dis- 
charge. A  narrow-bladed  bistoury  is  used,  and  a  puncture  is  made  which 
should  be  enlarged  should  pus  flow  alongside  of  the  knife.  Incisions  should 
be  made  in  a  vertical  direction  and  care  be  taken  that  they  are  not  too  far 
outward,  in  order  to  avoid  wounding  the  internal  carotid  artery. 

Tonsillotomy  is  performed  for  hypertrophic  tonsillitis.  The  simplest 
method  of  performing  this  operation  is  to  grasp  the  tonsil  with  a  tenaculum 
forceps  held  in  the  corresponding  hand  of  the  operator,  draw  it  toward  the 
median  line,  and  amputate  it  b}^  a  quick  stroke  of  the  probe-pointed  bistoury 


568 


THE    SURGERY    OF    THE    HEAD 


from  above  do^^Tlwa^d.  Should  the  surgeon  not  be  ambidextrous  he  mav 
remove  the  left  tonsil  first,  grasping  it  by  the  tenaculum  forceps  held  in  his  left 
hand.  He  then  stands  behind  the  patient,  the  head  is  bent  backward,  and  with 
the  tenaculum  forceps  in  his  left  hand,  he  uses  his  right  for  the  cutting.  In  the 
latter  case  he  makes  the  incision  from  below  upward.  Care  should  be  taken 
to  make  the  incision  as  close  as  possible  to  the  palatoglossal  fold  and  not  to 
drag  the  tonsil  too  far  from  its  bed  between  the  pillars  of  the  fauces,  else  danger- 
ous hemorrhage  may  occur  from  injur}-  to  the  tonsillar  branch  of  the  facial 
arter}-  or  to  the  large  branch  of  the  ascencUng  pharyngeal  from  the  ex- 
ternal carotid  which  takes  the  place  of  the  tonsillar  branch  of  the  facial 
when  the  latter  is  absent.  The  external  carotid  arter}-  can  scarcely  be 
injured  in  this  operation;  it  lies  at  least  three-fourths  of  an  inch  from  the 
base  of  the  tonsil. 

Special  instruments  ftonsillotomesj  have  been  devised  for  the  operation. 
Overestimation  of  the  difficulties  of  the  amputation  and  fear  of  injur}-  to  the 
carotid  arter}-  led  to  their  introduction.  While  this  fear  is  groundless,  still  the 
removal  may  be  facilitated  by  the  use  of  the  instnunents  particularly  in  the 
case  of  children,  and  where  a  general  anesthetic  is  not  given.  The  best  of  these 
is  that  sho\\-n  in  Fig.  339.  The  ring-shaped  extremity  is  slipped  OA-er  the  organ 
and  adjusted  T\-ith  the  index-finger  of  the  left  hand,  the  middle  and  ring  fingers 
depressing  the  tongue  at  the  same  time.     B}-  a  single  movement  the  tonsil  is 


Fig.  339. — Toxsillotome. 


seized  by  the  fork  of  the  instnmient.  elevated  and  made  tense,  and  amputated 
by  the  heretofore  concealed  blade.  Pencihng  the  mucous  membrane  of  the 
phar}-nx  and  ton.sils  T\-ith  a  10  or  20  per  cent  solution  of  cocain  hydrochlorate 
will  usually  produce  a  sufficient  ane.sthetic  effect.  ()r  general  anesthesia 
may  be  established  by  means  of  ether,  in  which  case  the  upright  position 
(F  r  e  n  c  h  '  .s)  or  the  dependent  head  position  of  Rose  may  be  employed. 
Hemorrhage  is  generally  arrested  by  gargles  of  ice- water;  this  failing,  pledgets 
of  cotton  wet  ^nth  spirits  of  turpentin  should  be  held  firmly  applied  to  the 
bleeding  surface.  The  tonsillar  arter}-  proper  passes  to  the  tonsil  along  the 
front  of  the  levator  palati  muscle,  and  as  the  latter  forms  a  portion  of  the  poste- 
rior surface  of  the  soft  palate,  pressure  from  behind  forward  against  this  struc- 
ture is  indicated. 

Latent  tuberculosis  of  the  tonsil,  manife.sting  its  pre.sence  by  hypertrophy 
of  one  or  more  of  the  lymphoid  organs  in  this  region,  has  been  obser\-ed 
CD  i  e  u  1  a  f  o  y).  The  bacilli  may  remain  latent  for  a  long  time,  recover}' 
finally  taking  place,  an  indurated  fibrous  condition  of  the  tonsil  remaining. 
Or  the  bacillus  may  find  its  wa}-  into  the  hmaphatic  vessels,  giving  rise  to 
enlarged  submaxillar}-  and  cervical  lymphatic  glands.  Pulmonar}'  tuberculosis 
may  finally  result. 

Malignant   Tumors. — Malignant   disease  of   the   tonsil   when   primary. 


THE    FAUCES,    PHARYNX,    AXD    XASOPHARYXX  569 

usually  occurs  as  sarcoma;  this  has  been  observed  in  patients  under  twenty. 
A  rapidly  growing  tumor  involves  the  tonsil  and  may  be  readily  mistaken  in  the 
beginning  for  simple  hypertrophy.  Attempts  to  remove  it  by  ordinary  methods, 
however,  will  reveal  its  true  nature,  and  be  followed  b>-  a  sharp  hemorrhage 
from  the  enlarged  tonsillar  artery.  Epithelial  carcinoma  is  usually  an  ex- 
tension of  the  disease  either  from  the  soft  palate  or  the  tongue,  usually  the 
former.  It  may  begin  on  the  pharyngeal  surface,  extend  to  the  oral  surface,  to 
the  pillars  of  the  fauces,  and  to  the  tonsil,  breaking  do^^-n  rapidly  into  ulceration. 
The  cervical  glands  become  involved  early.  I  have  observed  it  to  be  a  primary 
disease  in  one  case. 

External  Pharyngectomy.— This  operation  is  incHcated  in  malignant 
tiunors  of  the  tonsil  and  faucial  pillars  or  of  the  phar^Tigeal  wall.  The  patient 
is  prepared  beforehand  by  thoroughly  cleansing  the  buccal  and  pharvngeal 
cavities. 

The  patient's  head  is  placed  on  a  block,  well  extended,  and  turned  toward 
the  opposite  side.  An  incision  is  made  from  the  lobe  of  the  ear  along  the  an- 
terior edge  of  the  stemomastoid  muscle  to  a  point  three-fourths  of  an  inch 
below  the  level  of  the  hyoid  bone.  A  second  incision  commences  half-way 
between  the  angle  of  the  jaw  and  the  point  of  the  cliin  and  is  earned  down- 
ward and  backward  to  meet  the  lower  angle  of  the  first  incision.  The  triangu- 
lar-shaped flap  thus  marked  out  is  dissected  up  and  includes  the  tissues  doW 
to  the  sheath  of  the  muscles.  Upon  retracting  the  flap,  the  angle  of  the  jaw, 
portions  of  the  parotid  and  .submaxillaiy  glands,  the  stylohyoid  muscle,  the 
posterior  belly  and  a  portion  of  the  anterior  belly  of  the  cUgastric.  together 
with  the  omohyoid  muscle,  are  brought  into  xievr.  A  portion  of  the  hyoglossus 
is  visible  just  below  the  angle  of  the  jaw.  To  increase  the  working  space 
the  hyoid  attachment  of  the  styloh^'oid.  as  well  as  the  posterior  belly  of  the 
digastric,  may  be  severed.  Further  room  may  be  obtained  by  excision  of 
the  submaxillar}-  gland.  Finally,  under  certain  circiunstances  section  of  the 
inferior  maxilla  may  be  necessaiy  in  order  to  gain  access  to  the  parts  involved 
in  the  disease  (Billroth.  Che  ever),  in  which  case  a  prelmiinan- 
impression  of  the  teeth  should  be  taken,  and  an  interdental  splint  made  so 
that  these  may  be  preserved  in  their  proper  articulation  wliile  the  bone  is 
uniting. 

The  hyoglossal  nen-e  is  avoided,  the  stemomastoid.  the  stylohyoid  and 
the  posterior  belly  of  the  digastric,  as  well  as  the  important  vessels  and  nerves 
of  this  region,  are  bluntly  retracted  well  do^mward  and  backward,  the  mylo- 
hyoid being  drawn  anteriorly.  The  forefinger  and  middle  fingers  of  the  left 
hand  are  passed  into  the  mouth,  a  gag  having  been  previously  introduced, 
and  the  parts  crowded  dovsmward  and  outward.  The  phar\-nx  is  now  opened 
and  the  diseased  parts  extirpated.  The  thermocauter^-  applied  both  from 
the  ca\-ity  of  the  mouth  and  from  the  external  wound  may  be  used  at  this 
stage  in  cases  in  which  there  is  extensive  disease  of  the  faucial  pillars  and 
velum  as  well. 

The  above  procedure  furnishes  a  means  of  gaining  ready  access  to  the 
parts  ^-ithout  sacrificing  any  important  vessels  or  ner\-es  of  this  region.  The 
employment  of  the  thermocautery  facilitates  the  final  extirpation  of  the 
gro^^•th.  ^^-ithout  entrance  of  blood  into  the  pharynx  or  larynx,  and  furnishes 
protection  against  cancerous  infection  of  the  wound  as  well. 


570  THE  SURGERY  OF  THE  HEAD 

If  section  of  the  jaw  has  been  made,  the  bone  is  to  be  wired  and  the  inter- 
dental sphnt  finally  applied.  Under  these  circumstances  a  drainage-tube 
is  to  be  passed  into  the  pharj-nx  from  the  upper  and  posterior  angle  of  the  wound 
when  the  latter  is  sutured,  and  the  patient  fed  through  this. 

During  the  first  four  days  the  after-treatment  consists  in  flushing  the 
parts  every  t\\"o  hours  with  a  2  per  cent  solution  of  permanganate  of  potassium 


Fig.  340. — Exterx.vl  Pharyxgectomy. 

1,  Hyoglossus  muscle;    2,  retracted  posterior  belly  of  the  digastric  muscle;    3,  stylohyoid  muscle  di^•ided 

at  its  lower  attachment  at  (4);   5,  mylohyoid  muscle  retracted  anteriorly;    6,  body  of  mandible. 

through  a  catheter  passed  through  the  corresponding  naris.  This  is  followed 
by  a  solution  of  hydrogen  peroxid  applied  by  the  same  route.  The  diet 
should  be  limited  to  sterilized  milk.  A  decided  and  persistent  rise  of  tem- 
perature Avill  rec|uire  the  api^lication  of  a  5  or  10  per  cent  solution  of  chlorid 
of  zinc  to  the  parts  once  or  twice  a  day.  Septic  pneumonia  is  to  be  feared, 
as  in  all  extensive  operations  about  the  mouth  and  upper  respiratory  passages. 

FOREIGN  BODIES  IN  THE  FAUCES  AND  PHARYNX 

Predisposing  Causes. — These  may  be  classified  according  to  the 
regions  in  which  the  conditions  exist  as  follows  (Poulet):  (1)  the 
mouth  and  pharynx  :  loss  of  teeth,  facial  paralysis,  neoplasms,  and  nervous 
spasm;  (2)  affections  in  the  vicinity:  infiammatory  swellings  in  the  neck 
and  resulting  changes  in  the  course  of  the  alimentary  canal;  (3)  affections 
of  the  walls  :    constrictions  and  paralytic  dysphagia ;  (4)  predisposing  physi- 


THE    FAUCES,    PHARYNX,    AXD    NASOPHARYNX  571 

ologic  causes :  these  include  the  natural  irregularities  of  the  pharynx  which 
tend  to  the  arrest  of  difficult  substances  there.  The  particular  location  of 
the  foreign  body  is  freciuently  determined  hy  the  anatomic  structure  of  the 
parts. 

Objects  Taken  with  the  Food.— The  most  common  of  these  are 
small  fish-bones.  They  are  most  frequently  lodged  in  the  lingual  tonsil,  where 
they  are  sometimes  difficult  of  detection.  The  symptoms  are  pricking  sen- 
sations and  sometimes  pain,  which  the  patient  finds  difficulty  in  locating.  The 
patient  may  insist  that  the  fish-bone  is  lodged  in  the  vault  of  the  phar}-nx,  when 
inspection  reveals  it  projecting  from  the  surface  of  the  lingual  tonsil,  the 
bone  being  forced  upward  by  the  tongue  against  the  mucous  membrane  of  the 
nasopharynx  with  each  act  of  deglutition.  The  fish-bones  may  also  be  lodged 
in  the  faucial  tonsil,  the  posterior  pharyngeal  wall,  the  pyriform  sinuses,  or 
the  entrance  to  the  esophagus.  If  possible,  the  search  should  be  conducted 
by  the  aid  of  direct  or  reflected  sunlight.  Their  extraction  is  usually  easily 
accomplished   with   properly   cur\-ed   forceps. 

Sharp  and  Angular  Objects.— These  consist  of  pins,  needles,  etc., 
placed  in  the  mouth,  whence  they  make  their  way  into  the  fauces  or  pharynx. 
Small  sharp  bodies  give  rise  to  pain  on  attempts  at  swallowing,  coughing,  retch- 
ing, etc.  They  may  be  embedded  in  the  tissues  and  either  become  encapsu- 
lated or  give  rise  to  inflammation  and  suppuration.  Or,  if  sharp,  they  may 
migrate  and  appear  beneath  the  skin  of  the  neck  without  producing  suppura- 
tion. Excessive  hemorrhage  may  necessitate  ligation  of  the  common  carotid 
artery.  These  objects  may  make  their  way  into  the  Eustachian  tube,  finally 
emerging  through  the  external  auditory  canal.  The  removal  of  this  class 
of  foreign  bodies  is  usually  easy,  though  in  isolated  cases  it  has  been  necessary 
to  perform  external  pharyngotomy. 

Smooth  Round  Bodies.— These  are  rarely  arrested  in  the  fauces  or  pharynx, 
but  pass  at  once  into  the  esophagus  and  lodge  at  the  prominence  of  the  cricoid 
cartilage.  Failing  to  enter  the  esophagus  or  lodge  at  the  orifice,  they  are  found 
in  one  of  the  lateral  pharyngeal  sulci  (pyriform  sinuses).  The  symptoms  are 
difficulty  in  swallowing,  cough,  and  certain  reflex  convulsive  movements  of 
the  fauces.  If  the  larynx  is  involved  there  may  be  loss  of  voice.  Impaction 
of  this  class  of  foreign  bodies  is  rare.  The  foreign  body  is  to  be  located  by 
inspection  by  means  of  direct  and  reflected  light.  Digital  examination  may  aid 
in  the  diagnosis  and  is  frequently  instrumental  in  dislodging  the  object  directly 
or  by  the  reflex  vomiting  which  it  excites. 

Large  Objects  Irregular  in  Shape.— False  teeth  fixed  on  a  plate  which 
have  dropped  into  the  pharynx  during  sleep  constitute  the  type  of  this  class. 
This  accident  may  also  happen  during  the  administration  of  an  anesthetic,  as 
the  result  of  a  fall,  or  while  drinking  from  a  large  vessel.  Large  and  irregular 
pieces  of  bone  taken  with  the  food  are  rather  common.  They  lodge  either  in 
the  orifice  of  the  esophagus  or  in  one  of  the  lateral  pharyngeal  sulci.  In  cases 
of  large  irregular  objects,  death  may  result  from  suffocation  on  account  of  the 
difliculty  of  removal.  A  foreign  body  lodged  in  the  orifice  of  the  esophagus 
may  give  rise  to  S3'mptoms  demanding  tracheotomy. 

Finally,  foreign  bodies  in  the  fauces  and  pharynx  may  be  the  unsuspected 
cause  of  pain  on  swallowing,  progressive  emaciation,  attacks  of  hemorrhage 
following  ulceration,  and  perforation  of  the  posterior  laryngeal  wall.  The 
phar3'ngeal  wall  may  be  perforated  and  the  cer^4cal  vertebrae  eroded. 


572  THE  SURGERY  OF  THE  HEAD 

Living  Objects. — These  are  rare,  though  among  the  older  writings  there  are 
recorded  instances  of  all  sorts  of  small  living  animals  finding  their  way  into  the 
fauceS;  pharynx,  and  esophagus  (P  o  u  1  e  t) . 

INFLAMMATION  OF  THE  PHARYNX 

Acute  Pharyngitis. — Acute  inflammation  of  the  pharynx  alone  is  a  com- 
paratively rare  disease.  It  may  occur  in  connection  with  an  acute  inflamma- 
tion involving  the  soft  palate,  uvula,  and  the  pillars  of  the  fauces  (acute  fauci- 
tis) .  Acute  inflammation  of  this  region  usually  occurs  in  those  already  suffering 
from  a  chronic  catarrhal  inflammation  of  the  fauciai  region,  some  slight  ex- 
posure establishing  a  locus  minoris  resistentiae ,  as  the  result  of  Avhich  bacterial 
invasion,  particularly  streptococcus  infection,  occurs.  Other  predisposing 
causes  are  digestive  disturbances,  constitutional  SA'philis,  rheumatism,  and 
tuberculosis.  Acute  faucitis  also  occurs  at  the  commencement  or  in  the  course 
of  scarlet  fever,  measles,  smallpox,  erysipelas,  and  typhoid  fever.  It  is  some- 
times epidemic.  The  disease  frequently  commences  as  a  rhinopharyngitis.  The 
larynx  may  be  affected  because  of  contiguity. 

Symptoms. — A  peculiar  scratching  sensation,  followed  by  discomfort  in 
swallowing  and  finally  by  pain,  is  complained  of.  There  is  sometimes  a  decided 
rise  of  temperature;  a  chill  rarely  precedes  the  latter.  Headache,  earache, 
tinnitus,  and  impairment  of  hearing  may  be  present.  Purulent  otitis  media 
may  be  a  sec{uel.  Speech  becomes  painful  and  difficult.  A  grayish  viscid 
mucous,  followed  by  a  mucopurulent  secretion,  is  present.  Neuralgic  pains 
in  the  ear  through  Jacobson's  tympanic  branch  of  the  glossophar}-ngeal  are 
sometimes  complained  of.  Local  examination  reveals  a  velvetlike  appear- 
ance and  redness  of  the  mucous  membrane  from  hyperemia,  and  later  on  swell- 
ing of  the  mucosa.  Sometimes  a  paretic  condition  of  the  soft  palate  exists 
Hyperesthesia  is  frequently  marked.  In  mild  cases  resolution  occurs  in  from 
two  to  four  da^-^s.  Some  congestion  and  scanty  tenacious  discharge  may  con- 
tinue for  a  time. 

Treatment. — This,  in  the  commencement,  is  largely  medicinal  (the  use  of 
diaphoretics,  antipyretics,  etc.).  Duciuesnel's  aconitin  (gr.  5-^  every  hour 
until  the  constitutional  effects  of  the  drug  are  obtained)  is  recommended 
(B  o  s  w  o  r  t  h) .  Salol  is  also  valuable  (Jonathan  Wright).  Inha- 
lations of  the  steam  of  hot  medicated  solutions  (tincture  of  benzoin,  one  dram 
to  the  pint)  are  very  soothing.  When  the  secretion  appears,  an  astringent 
gargle  or  spray  of  chlorate  of  potassium  and  carbolic  acid  (2  per  cent  of  the 
former  and  1  per  cent  of  the  latter),  or  direct  applications  on  cotton  of  2  per 
cent  solutions  of  chlorid  of  zinc,  alum,  tannin,  etc.,  in  glycerin  are  to  be  em- 
ployed. Ear  symptoms  demand  early  attention.  Inflation  of  the  middle  ear 
(Valsalva's  or  Politzer's  method)  should  be  practised.  In  case  of 
catarrhal  or  purulent  collections  in  the  tympanic  cavity,  paracentesis  of  the 
drum  membrane  should  be  promptly  performed.  Prophylactic  treatment 
consists  in  attention  to  the  general  health,  the  wearing  of  proper  woolen  under- 
clothing, daily  tepid  or  cold  baths,  and  the  avoidance  of  wet  or  chilled  feet. 

Subacute  catarrhal  pharyngitis  is  best  treated  locally  by  means  of  the 
daily  application  of  a  2  to  10  per  cent  solution  of  iodin  and  iodid  of  potassium,, 
with  1  per  cent  of  carbolic  acid. 


THE    FAUCES,    PHARYXX,    AND    XASOPHARYXX  573 

Phlegmonous  Pharyngitis  (Erysipelas  of  the  Pharynx). — This  is  of 
undoubted  bacterial  oriiiiii.  The  microorganisms  probably  enter  through 
some  slight  traumatism  of  the  upper  epithelial  layers.  It  occasionally  occurs 
in  connection  with  acute  infectious  diseases.  Infection  of  the  deeper  layers  of 
th(^  mucosa  and  sul)niucosa  results  in  a  grave  form  of  the  disease  (acute  in- 
fectious phlegmonous  pharyngitis). 

Symptoms. — The  attack  is  sudden  and  violent  and  is  sometimes  accom- 
panied by  a  chill.  Considerable  rise  in  temperature  with  rapid  pulse  is  observed. 
Deglutition  is  difficult  and  painful.  The  throat  is  at  first  dry,  afterward 
there  is  a  tenacious  secretion.  The  tongue  is  coated  and  the  breath  offensive; 
salivation  may  occur.  The  mouth  is  opened  with  difficulty  on  account  of 
the  spread  of  the  inflammation  to  the  tissues  about  the  temporomandibular 
articulation.  The  peritonsillar  tissues  are  particularly  affected.  The  post- 
nasal space  may  be  in^•aded,  producing  obstruction.  Dyspnea  may  result 
from  extension  and  edema  of  the  glottis.  The  submaxillary  salivary  and 
lymphatic  glands  are  sometimes  swollen  and  tender.  The  inflammation  maj' 
subside  in  from  four  to  fourteen  days,  or  suppuration  may  occur.  In  the 
latter  case  the  symptoms  are  greatly  aggravated.  Spontaneous  rupture  of 
the  abscess  may  result  in  the  passage  of  pus  into  the  trachea.  The  pus  may 
find  its  way  into  the  esophagus,  or  burrow-  along  the  connective-tissue  planes 
into  the  tongue  and  the  mediastinum,  or  externally  beneath  the  deep  cervical 
fascia  and  into  the  submaxillary  glands.  Erosion  of  the  great  vessels  may 
occur.     General  septic  infection  may  take  place. 

Treatment. — A  general  tonic  form  of  treatment,  with  stimulants,  Avhen 
indicated,  should  be  followed.  The  local  use  of  a  5  or  10  per  cent  solution  of 
cocain  may  be  employed  before  taking  food.  It  may  be  necessar}'  to  resort  to 
rectal  alimentation.  Hot  antiseptic  gargles  and  hot  fomentations  of  carbolic 
acid  applied  to  the  neck  in  3  per  cent  solution,  are  indicated.  Free  incisions 
should  be  practised  as  soon  as  fluctuation  is  detected.  Even  if  the  suppura- 
tive process  is  not  reached  at  the  first  attempt,  relief  is  afforded  through  drain- 
age of  the  infiltrated  tissues.  The  pus  frequently  finds  an  exit  subsequently 
through  the  incisions.  The  cut  is  commenced  laterally  and  made  obliquely 
toward  the  median  line.  Frequent  gargling  A^dth  a  hot  antiseptic  solution  (2  per 
cent  solution  of  boric  acid)  should  follow  the  operation.  Tracheotomy  must  be 
resorted  to  if  edema  of  the  glottis  occurs.  If  suppuration  finds  its  way  ex- 
ternal'}-, incisions  in  the  lateral  region  of  the  neck  must  be  made. 

Ulcerative  Pharyngitis. — This  occurs  as  an  ulceration  of  the  super- 
ficial epithelial  layers  and  lymphoid  follicles.  It  frequently  occurs  in  hos- 
pital attendants,  pathologists,  and  medical  students  (hospital  sore  throat). 
It  is  marked  by  sore  throat,  high. fever,  and  prostration.  It  is  usually  of 
-short  duration.  The  treatment  consists  in  the  use  of  antipyretics  (phenacetin) , 
gargles  of  a  mild  antiseptic  solution  (permanganate  of  potassium),  and  the 
occasional  application  to  the  ulcers  of  tincture  of  iodin  on  a  small  cotton  swab. 

Gangrenous  Pharyngitis.— This  is  essentially  a  septicemic  process 
which  may  superA'ene  upon  scarlet  fever,  diphtheria,  measles,  typhoid  fe^'er, 
smallpox,  and  phlegmonous  pharyngitis.  Black  or  greenish-blue  spots  appear. 
The  breath  is  horribly  fetid.  The  temperature  is  at  first  high;  it  may  be- 
come subnormal.  The  prognosis  is  necessarih'  very  unfavorable.  The  treat- 
ment consists  in  supporting  measures  and  the  local  application  of  cleansing 
and  disinfecting  measures. 


574 


THE   SURGERY   OF   THE    HEAD 


TUMORS  OF  THE  NASOPHARYNX 

Lymphoma  (Adenoids).— This  is  essentially  a  disease  of  childhood. 
It  consists  of  a  hypertrophy  of  the  l}-mphoid  tissue  (phar}-ngeal  tonsil)  in 
the  vault  of  the  pharynx.  It  develops  in  infancy,  is  frecpently  congenital, 
and  ma}-  be  hereditary.  Inflammatory  conditions  are  frequently  the  exciting 
cause.  Nasal  stenosis  from  hypertrophic  rhinitis  or  deflected  septum,  or  both, 
may  be  present. 

Symptoms. — The  leading  symptoms  are  (1)  excessive  mucopurulent 
discharge;  (2)  an  altered  character  of  the  voice  from  loss  of  the  nasal  sound, 
m,  n,  and  ng  being  sounded  as  b,  d,  and  g;  (3)  chronic  otitis;  (4)  mouth- 
breathing  and  deficient  air-supply;  (5)  a  broadened  and  flattened  contour 
at  the  root  of  the  nose  and  a  semi-idiotic  facial  expression.  The  hard  palate 
is  raised  to  an  abnormally  high  level  and  the  dental  arch  is  narrowed.  The 
transverse  nasal  vein  crossing  the  bridge  of  the  nose  is  sometimes  enlarged 
(Spicer).  In  addition  to  these,  there  is  disturbed  sleep,  headache,  and 
in  certain  cases  cough  and  asthma. 

Diagnosis. — This  is  made  by  digital  exploration  and  posterior  rhinoscopic 
examination.     In  making  the    digital   examination  the  lower  portion  of  the 

septum  is  first  identified  and  this 
traced  until  the  growth  is  felt. 
Contraction  of  the  muscles  of  the 
]:)harynx  should  not  be  mistaken 
for  the  growth.  The  posterior 
rhinoscopic  examination  is  con- 
ducted with  the  tongue  depressed 
and  the  palate  relaxed.  Cocain 
anesthesia  will  assist  in  the  exami- 
nation. 

Treatment. — The  use  of  as- 
tringent sprays  will  lessen  the  dis- 
charge, and  perhaps  slightly  lessen  the  size  of  the  growth.  A  combination  of 
carbolic  acid  and  tannic  acid  (carbolic  acid,  1  grain;  tannic  acid,  40  grains; 
glycerin,  4  drams;  water,  3|  ounces)  is  useful  for  this  purpose.  The  galvano- 
cautery  is  advocated  by  some.  Complete  extirpation  by  operation  is  the  best 
method  of  treatment.  This  is  best  accomplished  by  means  of  the  cutting 
forceps  (Fig.  341),  aided,  when  necessary,  by  the  cutting  curet  (Fig.  342).  The 
child  is  anesthetized  and  placed  in  the  dependent  head  position,  if  chloroform 
is  employed ;  or  secured  to  a  chair  and  placed  in  the  upright  position  if  ether 
is  employed  (French).  A  mouth-gag  (Fig.  337)  is  introduced  and  a  palate 
retractor  used  as  rec{uired.  The  mass  of  tissue  must  be  completely  removed. 
Hemorrhage  is  free  at  first,  but  ceases  when  the  lymphoid  tissue  is  remoA-ed 
and  pressure  applied.     If  necessary',  the  posterior  nares  may  be  plugged. 

Fibromas. — These  are  sessile  growths  at  first,  though  they  may  finally 
become  pediculated.  They  usually  occur  in  males  at  about  the  age  of  puberty. 
The  growth  springs  from  the  periosteum  of  the  basilar  process  of  the  occipital 
bone  and  from  the  body  of  the  sphenoid  bone. 

S5rmptoms. — Repeated  attacks  of  epistaxis,  sometimes  violent  in  charac- 
ter, usually  occur  early  in  the  case.     As  the  growth  increases  in  size  the  pos- 


FiG.  341. — Cutting  Forceps  for  PlEmoval  of  Adex 
oius. 


THE    FAUCES,    THAKYXX,    AND    .XASOFHAKYXX 


575 


terior  nares  become  occluded  and  bilateral  nasal  stenosis  results.  This  is 
foUowctl  by  a  characteristic  facial  expression.  This  expression  increases 
until  the  broatlcning  and  flattening  of  the  face  become  a  well-marked  facial 
tleformity.  Finally,  the  pressure  of  the  growth  from  behind,  and  perhaps 
invasion  of  the  antrum  and  ethmoid  cells,  causes  protrusion  of  the  globe 
(exophthalmos).  A  discharge  of  tenacious  mucus  or  mucopus  in  the  fauces  and 
of  a  watery  secretion  from  the  nasal  cavity  occurs.  This  may  he  tinged  with 
blood.  Dyspnea  from  mechanic  obstruction  due  to  extension  of  the  growth 
downward  may  take  place. 

Diagnosis. — This  is  made  by  digital  and  posterior  rhinoscopic  examina- 
tion. The  examining  finger  sometimes  causes  hemorrhage.  The  growth  is 
dense  to  the  touch.  Inspection  reveals  an  irregularly  rounded  growth  of  a  light 
pinkish  color.     The  bilateral  stenosis  is  diagnostic. 

Prognosis. — This  is  grave  in  proportion  to  the  invasion  of  surrounding 
vital  parts,  and  the  dangerous  nature  of  the  operative  procedures  necessary 
for  their  extirpation,  when  they  have  attained  large  proportions.  The  tumors 
sometimes  disappear  by  sloughing. 

Treatment. — When  of  moderate  size  the  growth  may  be  removed  by 
repeated  applications  of  the  galvanocautery,  or  at  a  single  sitting  by  means  of 


Fig.  342. — Cutting  Curet  for  the  Removal  of  Adenoids  from  the  Nasopharynx. 
A,  Gottstein's  curet ;  B,  sharp  ring-shaped  curet. 


the  cold  wire  snare  (Jar  vis,  Fig.  282).  Piano  wire  (No.  5,  or  even 
larger)  should  be  employed.  The  section  should  be  made  very  slowly,  to 
avoid  hemorrhage.  For  larger  growths  separation  of  the  two  halves  of  the 
superior  maxilla  after  sawing  through  the  hard  palate  (see  page  577)  or  tem- 
porary osteoplastic  resection  of  the  upper  jaw  may  be  required. 

Myxofibromas. — These  spring  from  the  openings  of  the  posterior  nares. 
They  occur  more  frecpently  in  females  than  in  males,  and  are  generally 
observed  between  the  ages  of  fifteen  and  thirty.  The  growth  is  generally 
nonvascular. 

Symptoms. — The  tumor  is  of  comj^aratively  rapid  growth  and  gives  rise  to 
progressive  unilateral  nasal  stenosis.  There  may  be  some  hypersecretion.  The 
voice  is  deprived  to  some  extent  of  its  normal  nasal  resonance  and  articula- 
tion is  interfered  with  by  the  impingement  of  the  growth  on  the  soft  palate. 
The  growth  may  attain  considerable  size  without  giving  rise  to  marked  symp- 
toms. 

Diagnosis. — A  myxofibroma  is  to  be  differentiated  from  a  fibroma  by 
its  grayish-red  appearance,  greater  mobilit^^  and  the  absence  of  marked  vas- 
cularity. Epistaxis  does  not  occur  and  facial  deformity  is  wanting.  Myxo- 
fibromas occasionallv  recur  after  removal. 


576  -       THE  SURGERY  OF  THE  HEAD 

Treatment. — These  tumors  are  usually  easy  of  removal  by  means  of  the 
cold  wire  snare  introduced  through  the  nose,  or  they  may  be  twisted  off  b}; 
the  polypus  forceps.  Their  removal  may  be  facilitated  by  incision  of  the  soft 
palate.     The  parts  should  be  cocainized  beforehand. 

Chondroma. — This  is  exceedingly  rare  in  this  region.  Its  removal 
may  be  accomplished  by  temporary  removal  of  half  of  the  nose,  division  and 
separation  of  the  upper  jaw,  or  temporary  resection  of  the  latter. 

Sarcoma. — This  is  of  comparatively  rare  occurrence.  The  disease  is 
observed  as  rounded  masses,  sometimes  encapsulated,  springing  from  the 
deeper  layers  of  the  mucous  membrane  that  covers  the  basilar  process  of  the 
occipital  bone,  the  body  of  the  sphenoid  bone,  the  soft  palate  and  pharyn- 
geal wall,  extending  sometimes  to  the  upper  cervical  vertebrae  and  invading 
the  nasal  cavity,  orbit,  zygomatic  fossa,  and  anterior  portion  of  the  base  of 
the  brain.  The  growth  increases  more  or  less  rapidly  in  bulk,  and  the  pos- 
terior portion  of  the  brain  may  be  invaded  by  involvement  and  perforation 
of  the  basilar  process.     It  may  occur  at  almost  any  time  of  life. 

Symptoms. — The  symptoms  are  those  of  nasopharyngeal  tumors  in  gen- 
eral, with  the  addition  of  the  presence  of  a  seromucous,  ichorous,  and  offen- 
sive discharge,  which  vitiates  the  inspired  air,  impairs  digestion,  and  thus 
leads  to  deterioration  of  the  general  health.  Interferences  with  swallowing 
and  breathing  from  mechanic  pressure  occur  as  the  growth  enlarges.  Hear- 
ing is  impaired  by  encroachment  of  the  tumor  upon  the  orifice  of  the  Eustachian 
tube.     Epistaxis  occasionally  occurs. 

Diagnosis. — A  grayish-yellow  lobulated  tumor  with  a  soft  pultaceous  feel 
is  present.  The  thin,  watery,  ichorous,  and  offensive  discharge  should  always 
excite  the  surgeon's  suspicion.  The  only  certain  means  of  diagnosis  consists 
in  the  removal  of  a  piece  for  microscopic  examination. 

Prognosis. — This  is  unfavorable.  Small  round-celled  tumors  grow  rapidly 
as  compared  with  the  spindle-celled  variety,  but  death  finally  takes  place,  either 
from  the  growth  or  from  the  operative  attempt  for  its  removal.  A  single 
authenticated  instance  of  cure  is  recorded  (Bosworth's). 

Treatment. — Extensive  radical  operative  procedures  are  generally  useless. 
They  frequently  fail  even  to  alleviate  the  sufferings  of  the  patient,  and  many 
patients  die  on  the  table,  or  shortly  after  the  operation.  Wliile  still  of  moderate 
size,  the  cold  wire  snare  is  most  applicable  for  its  removal,  as  in  fibroma.  Wide 
access  to  the  growth  may  be  obtained  by  incising  the  palate.  In  larger  growths, 
provided  adjacent  vital  parts  have  not  been  invaded,  the  surgeon  is  sometimes 
justified  in  consenting  to  radical  operation,  though  not  always  in  advising  it. 
In  advanced  cases  involving  the  antrum,  orbit,  zygomatic  fossa,  or  spheno- 
maxillary fossa,  he  should  refuse  to  interfere  in  this  manner. 

Carcinoma. — The  occurrence  of  carcinomatous  deposits  in  the  nasophar^mx 
is  less  frequent  than  the  occurrence  of  sarcoma.  The  symptoms  and  clinical 
course  are  similar  to  those  of  sarcoma.  Microscopic  examination,  if  a  portion 
is  removed  for  the  purpose,  will  establish  the  diagnosis.  Secondary  involve- 
ment of  the  glandular  and  other  tissues  of  the  neck  occurs  early  in  the  disease. 
The  youngest  patient  recorded  was  thirty-seven;  the  oldest,  seventy-five. 
Treatment,  to  be  of  any  service,  must  be  instituted  early  in  the  case  and  be 
radical  in  character. 


THE    FAUCES,    PHARYNX,    AND    NASOPHARYNX  577 

Operations  for  Gaining  Access  to  the  Nasopharynx  for  the  Removal 
of  Tumors. — The  Nasal  Route. — ^The  incision  i«  made  slightly  to  one 
side  of  the  middle  line  of  the  nose.  The  lateral  nasal  cartilage  and 
the  nasal  bone  are  divided  on  the  same  line.  If  more  room  is  needed,  the 
nasal  process  of  the  superior  maxilla  is  divided  from  below  upward,  just  in 
front  of  the  lacrimal  sac,  the  root  of  the  nasal  bone  chiseled  across,  and  the 
corresponding  side  of  the  nose  thrown  upward  (Kocher).  Or,  the  nasal 
cavity  may  be  exposed  by  detaching  the  nose  and  turning  it  upward.  Two 
incisions  are  made,  one  on  each  side  of  the  nose,  commencing  at  a  point  just 
internal  to  the  lacrimal  sac.  These  are  carried  downward  to  the  junction  of 
the  ala  nasi  of  each  side  with  the  lip,  and  are  thence  extended  into  the  nasal 
cavity  by  cutting  through  the  nasal  bones  and  the  nasal  process  of  the  maxilla. 
Finally,  the  septum  is  divided  and  the  nose  turned  up  (Lawrence). 

The  Palatal  Route. — In  this  method  the  hard  and  the  soft  palate  are 
divided  and  a  portion  of  the  former  removed.  A  median  incision  is  made  down 
to  the  bone  in  the  hard  palate,  and  extended  so  as  to  bisect  the  soft  palate  and 
uvula.  The  mucoperiosteal  soft  parts  are  detached  and  turned  aside,  a  trans- 
verse cut  on  each  side  facilitating  this.  The  hard  palate  and  a  portion  of  the 
vomer  are  chiseled  out  in  the  shape  of  a  quadrilateral  piece  of  bone,  and  the 
posterior  part  of  the  nasal  cavity  and  the  nasopharynx  exposed  (N  e  1  a  t  o  n  , 
Gussenbauer). 

Annan  dale  operated  as  follows :  The  mucous  membrane  of  the  lip 
is  freely  detached  at  its  reflection  on  the  jaw  and  the  lip  turned  upward  so 
as  to  expose  the  anterior  nares.  The  bony  septum  of  the  nose  is  divided  at  its 
attachment  to  the  superior  maxilla  with  cutting  forceps.  A  gag  is  now  intro- 
duced and  an  incision  is  made  in  the  median  line  of  the  hard  palate  down 
to  the  bone.  An  incisor  tooth  is  extracted,  a  metacarpal  saw  introduced  in  the 
naris,  and  the  hard  palate  sawed  through  the  median  Hne.  If  necessary,  the 
soft  palate  is  also  divided.  To  gain  additional  room,  the  Hp  and  cheeks  may 
be  detached  at  their  reflection  on  the  gums,  and  both  halves  of  the  upper 
jaw  chiseled  through  transversely  outward  and  backward  from  the  anterior 
nares  (Kocher).  The  two  halves  of  the  upper  jaw  are  now  drawn  apart 
with  sharp  hooks,  the  mucous  membrane  of  the  floor  of  the  nose  divided,  the 
vomer  drawn  aside,  and  the  projecting  turbinated  bones  excised.  The  tumor 
is  now  completely  exposed  and  removed  through  the  gap.  Ligation  of  both 
external  carotid  arteries  should  precede  the  operation  on  the  jaw. 

The  Maxillary  Route. — The  method  of  osteoplastic  resection  of  the 
upper  jaw  gives  good  access  to  tumors  attached  to  the  basilar  process  of  the 
occipital  bone  and  its  neighborhood.  Both  external  carotid  arteries  may 
be  ligated  preliminarily.  The  operation  is  the  same  as  for  typic  resec- 
tion of  one-half  of  the  upper  jaw,  except  that  the  soft  parts  of  the  face  are  not 
detached  from  the  bone  after  the  skin  incisions  are  made.  The  frontal  process 
of  the  malar  bone  must  be  divided  through  a  separate  incision.  The  separated 
half  of  the  jaw  is  to  be  turned  back  with  the  attached  soft  parts.  After  removal 
of  the  tumor  the  parts  are  restored  and  the  soft  parts  sutured. 

In  all  operations  of  the  kind  described  the  venous  hemorrhage  is  sometimes 

excessive.     Kocher  recommends  that  a  sixth  of  a  grain  of  sulfate  of  morphin 

be  given  half  an  hour  before  the  operation,  and  a  minimum  amount  of  chloroform 

administered  through  a  tracheotom^-  tube,  with  the  patient  sitting  upright. 

38  "  " 


578  THE  SURGERY  OF  THE  HEAD 

For  operations  in  the  nasopharynx  French  recommends  that  the  patient 
be  secured  to  a  chair,  the  back  of  which  is  lo^\•ered,  and  that  ether  be 
administered.  The  chair  is  then  carefully  raised  until  the  patient  is  in  the 
upright  position,  when  the  operation  is  proceeded  with. 


THE  EAR 

Only  those  common  affections  of  the  ear  coming  under  the  observation  of 
the  general  surgeon  will  be  considered  in  this  connection. 

Injuries  of  the   Auricle    and    Cartilaginous    Auditory    Meatus. — 

Incised  wounds  of  the  auricle  are  usualh'  followed  by  retraction  of  the  skin 
layers,  leaving  the  cartilage  more  or  less  exposed.  Wliile  there  is  no  objection 
to  suturing  both  the  cartilage  and  the  skin,  carefully  applied  fine  silk  sutures  at 
the  skin  edges  alone  will  suffice.  Care  should  be  taken  in  applying  the  dressings 
to  maintain  the  proper  shape  of  the  parts,  or  serious  deformity  may  result.  Even 
if  but  a  slight  connection  of  skin  is  maintained  between  the  partially  severed 
portion  and  the  auricle,  the  attempt  should  be  made  to  restore  the  former, 
since  parts  even  completely  severed  have  reunited  when  promptly  replaced. 

An  unsightly  slit  is  sometimes  left  in  the  lobule  by  the  tearing  out  of  an 
earring.  This  also  happens  from  slow  ulcerative  action,  the  weight  of  the 
earring  slowly  separating  the  lobule.  Freshening  the  surfaces  of  the  gap  and 
suturing  give  uniformly  good  results  in  the  so-called  coloboma  of  the  lobule. 

Frost=bites  of  the  auricle  are  of  not  infrequent  occurrence,  through 
which  small  portions  of  the  upper  border  are  lost.  Attempts  at  plastic 
replacement  have  not  heretofore  met  with  very  encouraging  success. 

Othematoma  of  the  auricle  is  a  peculiar  affection  occurring  particularly 
in  the  insane.  It  consists  of  an  isolated  subperichondrial  effusion  of  blood 
near  the  free  edge  of  the  auricle,  at  either  its  anterior  or  its  posterior  wall,  a 
fiat  convex  swelling  resulting.  Coagulation  does  not  take  place,  in  this  re- 
spect the  effusion  resembUng  cephalhematoma.  In  the  insane  the  presence 
of  an  othematoma  is  frequently  made  the  basis  for  accusations  of  maltreat- 
ment against  those  in  charge.  It  is  due,  in.  all  probability,  to  vasomotor 
disturbances.  Treatment  by  massage  should  first  be  tried.  This  failing, 
aseptic  incision  and  drainage  will  result  in  prompt  cure,  the  loosened  peri- 
chondrium very  readily  reattaching  itself  to  the  cartilage. 

Injuries  of  the  Bony  Parts  of  the  Ear.— Isolated  fractures  of  the 
bony  auditory  meatus  sometimes  occur  from  forcible  impact  of  the  con- 
dyle of  the  lower  jaw,  the  result  of  a  fall  on  the  chin.  In  fractures  of 
the  base  of  the  skull  in  the  middle  fossa  the  fissure  passes  to  the  apex  of 
the  petrous  portion  of  the  temporal  bone  and  thence  to  the  lateral  wall  of  the 
skull.  The  usual  signs  of  fracture  of  the  base  of  the  middle  fossa,  with  rup- 
ture of  the  membrana  tympani,  ?'.  e.,  hehiorrhage  from  the  ear  and  the 
escape  of  cerebrospinal  fluid,  are  present.  In  the  differential  diagnosis  of 
fractures  in  this  region  and  injury  to  the  drum  membrane  alone,  the  amount 
of  bleeding,  together  with  the  presence  of  sugar  in  appreciable  quantities  in 
whatever  serous  oozing  is  present,  is  to  be  considered.  In  case  of  compound 
fractures,  even  considerable  quantities  of  brain  matter  from  the  lateral  lobes 
of  the  cerebellum  may  escape  wdthout  marked  disturbance,  owing  to  the  ab- 
sence of  important  function  in  this  locahty.  Injuries  of  the  petrous  portion 
of  the  temporal  bone  by  direct  force,  e.  g.,  by  projectiles,  give  rise  to  compound 


Til  10  i:ak 


579 


fractures,  as  well  as  to  fatal  hemorrhage  cither  from  the  internal  carotid 
artei'v  as  this  vessel  passes  through  llic  cai'olid  canal,  from  the  transverse  sinus, 
or  from  the  middle  meningeal  artery  from  extension  of  the  fissure  to  the  upper 
margin  of  the  sciuamous  portion  of  the  temporal  bone.  Careful  packing  of 
the  wound  will  usually  suffice  to  arrest  the  hemorrhage,  if  this  comes  from  the 
sinus.  In  some  cases  of  rupture  of  the  internal  carotid  not  proving  immediately 
fatal,  the  corresponding  common  carotid  artery  has  been  successfully  ligated. 
In  others,  howcA^er,  this  has  failed,  even  when  supplemented  by  ligation  of  the 
other  common  carotid. 
The  uncertaintv  of  this 
procedure  is  explained  by 
the  freedom  of  the  arte- 
rial   cerebral    circulation 

through     the      circle      of  Fig.  343.-Tubular  Ear  Speculum. 

Willis,    as    derived   from 

the  terminals  of  the  vertebrals  when  the  common  carotids  are  ligated.  In 
cases  of  secondary  hemorrhage,  therefore,  following  injury  in  this  region,  as  well 
as  in  cases  of  hemorrhage  resulting  from  erosion  of  the  internal  carotid  occur- 
ring in  the  course  of  caries  of  the  petrous  portion  of  the  temporal  bone,  the 
preferable  course  is  to  pack  the  canal  A^ery  tightly  with  iodoform  gauze. 

In  order  to  guard  as  much  as  possible  against  septic  meningitis  and  en- 
cephalitis in  injuries  in  this  locality,  every  aseptic  precaution,  including  anti- 
septic irrigation  and  sterile  protective  dressings,  should  be  taken. 

Both  the  facial  and 
the  auditory  nerves  may 
be  injured  in  fractures  of 
the  petrous  portion  of  the 
temporal  bone.  These 
injuries  are  surgicallv  ir- 
reparable. Spontaneous 
restoration  of  function 
may  take  place,  however. 
Foreign  Bodies  in 
the  External  Auditory 
Canal.— Children  often 
introduce  such  articles  as 
peas,  beans,  and  buttons 
into  the  external  audi- 
tor}-  meatus.  The  for- 
eign bodies  most  fre- 
quentty  found  in  adults 
are  cotton  plugs,  placed 
in  the  ear  with  the  delusive  belief  that  these  will  prevent  "catching  cold," 
the  presence  of  the  cotton  being  forgotten.  The  cerumen  and  cotton  com- 
bine to  form  a  dense  hard  mass   completely  filling  the  canal. 

Plugs  of  cerumen  having  their  origin  in  excessive  secretion  of  cerumen 
from  chronic  inflammation  of  the  ceruminous  glands  may  give  rise  to  the 
symptoms  of  true  foreign  bodies  in  the  ear,  the  mass  obstructing  the  canal 
and  producing  impairment  of  hearing;  in  some  cases  they  may  cause  annoy- 
ing and  persistent  tinnitus. 


Fig.  344. — Electric  Light  Otoscope. 


580  THE  SURGERY  OF  THE  HEAD 

Foreign  bodies  and  masses  of  cerumen  are  usually  easily  discovered  by 
inspection,  the  auricle  being  retracted  so  as  to  straighten  the  canal  by  grasping 
it  at  its  upper  edge.  If  the  foreign  body  is  small,  it  may  be  necessary  to  use 
an  ear-speculum  (Fig.  343).  The  common  tubular  ear  speculum  made  of 
metal,  with  the  interior  polished  to  improve  the  illumination,  serves  an  ex- 
cellent purpose.  The  electric  light  otoscope  is  a  very  useful  instrument  for 
examining  the  deeper  parts  of  the  canal  and  the  drum  membrane  (Fig.  344). 
In  the  case  of  the  common  tubular  speculum  the  patient  is  seated  with  the 
ear  to  be  examined  opposite  a  window,  and  the  light  reflected  with  a  head 
band  mirror.  If  the  direct  rays  of  the  sun  are  used  or  an  artificial  source  of 
light  is  employed,  the  polished  interior  of  the  tubular  speculum  is  somewhat 
dazzling  to  the  examiner,  and  the  instrument  with  dull  finish,  or  one  made 
of  hard  rubber,  is  to  be  preferred.  In  examining  for  foreign  bodies  the  sur- 
geon should  not  be  misled  by  the  brownish  layers  of  cerumen  lying  against 
the  walls  of  the  auditory  meatus.  In  the  case  of  a  foreign  body  the  inspection 
will  sometimes  reveal  whether  or  not  a  space  is  left  between  the  latter  and 
the  wall  of  the  meatus,  into  which  an  instrument  may  be  introduced  for  the 
purpose  of  effecting  the  extraction  from  within  outward. 

A  probe,  if  employed  at  all,  should  be  used  with  the  greatest  care.  Its 
use  without  the  aid  of  the  speculum  gives  but  very  little  information,  since 
its  contact  with  the  bony  walls  closely  covered  with  skin  and  periosteum  will 
greatly  resemble  the  touch  of  a  foreign  body. 

Foreign  bodies  should  always  be  removed,  for,  though  exceptionally  they 
may  remain  innocuous  for  a  time,  they  will  eventually  set  up  irritation,  and 
finally  suppuration,  which  will  extend  to  the  tympanum  and  impair  the  func- 
tion of  hearing,  and  lead  to  destructive  changes  in  the  bone  itself ;  the  latter 
may  even  threaten  life  by  setting  up  meningitis.  It  is  as  dangerous,  how^ever, 
to  attempt  to  extract  these  bodies  roughly  without  proper  illumination  as  it  is 
to  permit  them  to  remain. 

Removal  of  Foreign  Bodies  from  the  External  Meatus. — Small  foreign 
bodies  w^hich  do  not  completely  fill  the  meatus  are  best  removed  by  forcible 
syringing  with  a  large  sized  piston  syringe  with  ring  pieces  for  firm  grasping 
(Fig.  345).  The  syringe  is  worked  with  the  right  hand,  the  left  grasping  the 
auricle  and  retracting  it  upward  and  backward  so  as  to  straighten  the  canal 
and  give  free  access  and  exit  to  the  lukewarm  water  employed. 

In  the  case  of  foreign  bodies  deeply  placed  the  wire  curet  or  a  fenestrated 
ear  spoon  sometimes  accomplishes  the  purpose  with  facility.  If  a  space  exists 
between  the  foreign  body  and  the  meatus,  it  will  usually  be  found  in  the  direc- 
tion of  either  the  upper  or  the  lower  wall.  A  small  hook  introduced  flatwise  and 
then  turned  so  as  to  engage  the  foreign  body  is  often  successful.  An  extracting 
instrument  may  be  improvised  from  a  hairpin.  Whatever  form  of  instrument 
is  employed  it  must  be  introduced  with  strong  pressure  against  the  wall  of  the 
meatus  or  canal,  so  as  to  gain  as  much  room  as  possible,  as  well  as  to  lessen  the 
friction  as  it  glides  past  the  foreign  body.  Foreign  bodies  swollen  by  attempts 
to  flush  them  out  with  water,  or  from  secretions  excited  by  their  presence,  may 
be  reduced  in  size  by  contact  with  glycerin  for  some  hours.  The  instrument 
may  then  be  introduced  alongside  the  softened  cortical  layers.  Softened  beans 
will  sometimes  split  longitudinally  and  admit  of  easy  extraction. 

In  the  case  of  nervous  children,  and  in  anv  case  in  which  much  pain  is  caused 


THE    EAR 


581 


by  the  inaiii])ulation,  the  patient  should  be  anesthetized.  Hard  impacted 
foreign  bodies  may  even  require  temporary-  loosening  of  the  auricle  and  cartilag- 
inous meatus  through  an  incision  made  from  behind.  This  usually  permits 
direct  access  to  the  foreign  body.  Such  incisions  should  be  made  Avith  every 
aseptic  precaution,  since  suppuration  in  this  locality  may  involve  destruction 
of  the  membrana  tympani. 

Ceruminous  plugs  are  best  removed  by  forcible  syringing.  In  case  these 
should  ])rove  obstinate  they  may  be  softened  by  the  previous  application  of  a 
weak  solution  of  carbonate  of  soda  in  water  and  glycerin. 

Inflammation  of  the  External  Ear.— The  usual  inflammatory  affections 
of  the  face  and  scalp,  such  as  eczema,  impetigo,  etc.,  attack  the  auricle. 
Erysipelas  gi\-es  rise  to  the  formation  of  vesicles  at  the  upper  edge  of  the 
auricle.  Se\'ere  phlegmonous  inflammations,  however,  are  rare,  on  account  of 
the  absence  of  loose  connective  tissue.  Furuncles  are  also  rare,  on  account  of 
the  superficial  location  of  the  hair-follicles. 

Lupus  may  extend  from  the  cheek  to  the  ear.  This  usually  occurs  in  the 
exfoliating  form  of  the  disease.  The  cicatricial  atrophy  may  result  in  the 
disappearance  of  nearly  the  entire  auricle.  Lupus  of  the  lobule  has  been 
described  as  an  isolated  disease  in  which  the  whole  substance  of  the  lobule  is 
converted  into  pale  red  tissue.  In  some  cases  the  disease  is  arrested  only  by 
the  removal  of  the  lobule. 

Otitis  Externa. — Ex- 
ternal otitis  appears  in 
the  following  forms: 

1.  Eczema  of  the  ex- 
ternal auditory  meatus, 
occurring  specially  in 
strumous  children  and 
accompanying  eczema  of 
the  skin  of  the  external 

ear.     The  vesicles  discharge  a  serous  fluid,  a  part  of  which  escapes  from  the  ear 
while  some  remains  and  dries  in  hard  crusts -on  the  walls  of  the  canal. 

2.  Furuncle. — This  commences  with  swelling  of  the  skin  lining  the  external 
auditory  meatus,  and  develops  with  violent  pains  as  the  thin  skin  is  tightly 
stretched  on  the  underlying  perichondrium  and  periosteum.  The  "local 
symptoms  partake  of  the  character  of  periostitis.  There  is  diffuse  swelling 
with  absence  of  localized  elevation  corresponding  to  the  site  of  infected  seba- 
ceous glands  or  hair-follicles,  so  characteristic  of  the  affection  as  it  occurs  else- 
where. The  furuncular  character  of  the  lesion,  however,  is  established  by  the 
occurrence  of  an  isolated  connective-tissue  necrosis ,  unless  this  is  anticipated 
-by  early  and  free  incision,  which  always  gives  prompt  relief.  Furuncles  should 
be  incised  early.  The  curved  and  pointed  bistoury,  or  the  tenotome,  best  serves 
the  purpose  for  the  incision.  If  an  abscess  of  the  ear  drum  or  a  collection  of  pus 
behind  the  tympanum,  as  shoAMi  by  a  bulging  of  the  latter,  occurs,  the  puncture 
is  best  made  with  the  point  of  a  cataract  needle.  Illumination,  both  for  the 
purpose  of  cUagnosis  and  for  the  guidance  of  the  instrument  in  case  of  puncture, 
is  here  absolutely  necessary. 

3.  Traumatic  suppuration  following  injuries  or  due  to  the  presence  of 
foreign  bodies. 


Fig.  345.— Eab  Syringe. 


582  THE  SURGERY  OF  THE  HEAD 

4.  Secondary  suppuration  consequent  upon  suppurative  perforation  of 
the  memljrana  tympani  as  a  result  of  otitis  media. 

Otitis  media,  which,  with  otitis  interna,  belongs  essentially  in  the  domain 
of  the  otologist,  will  be  only  superficially  considered  here.  Not  only  is  the  drum 
membrane  perforated,  but  the  mastoid  cells  are  also  affected.  The  resulting 
caries  is  not  necessarily  tuberculous,  though  it  may  be  of  this  character  if  the 
original  suppuration  in  the  tympanic  cavity  Avas  tuberculous.  The  latter, 
however,  is  usually  metastatic,  and  occurs  especially  after  measles  and  scarla- 
tina. Finally,  a  true  tuberculous  myelitis  may  occur  in  the  mastoid  process 
without  preceding  disease  of  the  middle  or  external  ear. 

Tumors  in  the  Region  of  the  Ear.— Deformities  of  the  Auricle. — 
So-called  polypi  of  the  external  auditory  meatus  are  A^ery  frequently  made  up 
of  granulation  tissue  originating  in  the  suppurating  surfaces  of  an  external 
otitis,  or  in  cases  of  otitis  media,  from  the  mucous  membrane  of  the  tympanic 
cavity.  In  the  latter  case  the  tumor  grows  through  a  large  defect  in  the 
membrana  tympani  and  projects  into  the  external  auditory  meatus.  Some- 
times this  granulation  tissue  becomes  covered  with  a  layer  of  epidermis,  and 
the  name  of  granuloma  is  given  to  the  resulting  tumor.  These  growths 
occasionally   persist  in   this   shape   for  a   long   time  after   the   suppuration 


Fig.  346-. — Wilde's  Aural  Polypus  Snare. 

has  ceased,  and  from  the  fact  that  they  finally  become  pediculated  the  name  of 
"aural  polypi"  is  more  or  less  justified.  They  are  even  said  to  have  become 
finally  the  seat  of  angiosarcomas.    * 

When  these  granulating  masses  are  sessile  and  soft,  they  are  to  be  treated 
by  scraping  and  cauterization;  when  solid,  they  will  require  excision.  Those 
belonging  to  the  pediculated  variety  are  easily  and  satisfactorily  removed  with 
Wilde's  snare  (Fig.  346).  Removal  of  the  granula  or  polypus,  however, 
will  not  improve  the  hearing  in  cases  in  which  the  growth  follows  otitis  media, 
since  the  preceding  suppurative  process  in  the  ixiiddle  ear  has  already  done 
its  damaging  work. 

Both  benign  and  malignant  growths  occur  at  the  auricle  and  in  its  neigh- 
borhood. Dermoids  are  found  springing  from  the  upper  branchial  cleft ;  their 
favorite  location  is  either  in  front  of  the  auricle  or  behind  it.  They  are  less 
frequently  found  at  the  upper  or  the  lower  portion  of  the  latter.  They  vary 
in  size  from  a  hazelnut  to  a  hen's  egg.  Those  of  smaller  size,  and  particu- 
larly those  lying  in  front  of  the  auricle,  are  usually  very  superficial  and  are 
often  mistaken  for  simple  atheromas.  Those  extending  into  the  deeper  struc- 
tures are  somewhat  difficult  of  removal. 

Auricular  appendages  have  already  been  referred  to  in  the  section  on 
tumors.     They  are  connected  with  the  processes  of  development,  and  occur 


Til  10    FAR  583 

not  iiifiv(iu(>iill>-  will)  inacrostonia.  1liey  are  generally  found  at  the  anterior 
edge  of  tlu>  tragus.  In  addilioii  to  (hose  containing  a  nucleus  of  cartilage, 
others  have  been  found  with  a  small  ()])cning  corresponding  to  an  inversion 
of  the  epidermis.  These  skin-covered  remnants  of  cartilage  have  also  been 
found  over  the  sternomastoid  (L  o  s  s  e  n).  They  Iku'c  been  found  springing 
concurrently  from  both  sides.     'Jdiey  may  be  easily  and  safely  removed. 

Angiomas  occur  as  congenital  tumoi's  at  the  auricle  and  may  give  rise 
to  dangerous  symptoms  in  connection  with  pregnancy  (see  page  227).  Of 
benign  tumors,  atheromas,  enchondromas,  and  fibromas  are  only  occasionally 
found  in  this  region;  they  rarely  develop  to  an  excessive  size.  The  last  named, 
together  with  a  condition  a]iproximating  elephantiasis,  attacks  by  preference 
the  lobule. 

Epithelial  carcinoma  sometimes  attacks  the  auricle.  It  occurs  as  a  flat 
ulcer  and  may  linall}-  destroy  the  auricle.  It  develops  gradually,  the  destruc- 
tive process^  is  slow,  and  the  prognosis  in  case  of  early  and  wide  extirpation 
is  comparatively  good.  Lymj^hatic  glandular  involvement  takes  place  in  the 
parotid,  region,  behind  the  angle  of  the  jaw,  and  at  the  anterior  edge  of  the 
sternomastoid. 

Efforts  to  correct  the  deformity  following  amputation  of  the  ear  by  plastic 
operations  (otoplasty),  as  well  as  those  designed  to  supplement  congenital 
defects,  have  met  with  but  indifferent  success.  While  efforts  to  replace  the 
lobule  by  skin  flaps  from  the  neighljorhood  are  fairly  successful,  the  compli- 
cated shape  of  the  auricle  has  heretofore  defied,  to  a  great  extent,  the  liest 
efforts  of  plastic  surgery.  ]\Iore  or  less  improvement,  however,  may  some- 
times be  obtained. 

Projecting  ears,  in  which  the  auricle  projects  abnormally,  may  be  cor- 
rected by  the  removal  from  the  auricle  of  an  elliptic  shaped  portion  of  proper 
dimensions.  The  sutures  are  so  placed  as  to  include  both  skin  and  cartilage 
on  the  outer  aspect,  and  the  skin  alone  on  the  inner  aspect. 

^  Mastoiditis. — This  is  usually  due  to  an  extension  of  infection  from  the 
middle  ear.  Primary  mastoiditis  is  rare.  The  pathologic  changes  consist 
of  thickening  of  the  lining  membrane  of  the  cells  of  the  mastoid,  followed 
in  some  cases  by  a  deposit  of  new  bone,  which  may  finally  lead  to  complete 
obhteration  of  the  cells.  In  other  cases  necrosis  occurs,  with  the  formation 
of  a  sequestrum.  Or,  gradual  disintegration  may  occur,  with  discharge  of 
detritus  and  pus  through  the  external  ear.  When  the  evacuation  takes  place 
externally,  this  may  occur  either  behind  the  ear,  into  the  external  meatus, 
or  into  the  digastric  fossa.  When  internally,  the  fluid  finds  exit  either  through 
the  roof  of  the  antrum  or  through  that  of  the  tympanic  vault,  into  the  middle 
cranial  fossa  or  into  the  posterior  cranial  fossa  along  the  groove  which  lodges 
the  lateral  sinus  (sinus  thrombosis,  see  page  584). 

The  external  discharge  of  pus  does  not  relieve  the  case  of  its  dangers, 
particularly  in  children,  since  intracranial  infection  may  subsequent!}-  take 
place  through  the  incompletely  ossified  sutures.  Invasion  of  the  cranial 
cavity  may  lead  to  diffuse  septic  meningitis  (see  page  457)  or  to  a  circum- 
scribed inflammation  and  epidural  abscess.  Finally,  the  intracranial  con- 
tents may  become  infected  through  the  free  anastomosis  of  the  vessels  of  the 
parts,  and  thrombosis  of  the  lateral  sinus  (see  page  464)  or  abscess  of  the  brain 
substance  follow  (see  pages  459,  462,  and  586). 


584  THE  SURGERY  OF  THE  HEAD 

The  symptoms  of  mastoiditis  arc  intense  pain  over  the  mastoid,  which  is 
most  severe  at  niglit,  more  or  less  constitutional  disturbance,  and  tenderness  on 
deep  pressure,  particularly  over  the  posterior  margin  of  the  canal.  A  pre- 
vioush'  existing  aural  discharge  is  diminished  or  ceases  altogether.  In  children 
tumefaction  behind  the  auricle  may  be  present.  Perforation  of  the  cortex 
is  announced  by  the  presence  of  a  purulent  material  between  the  overlying 
soft  parts  and  the  bone.  Invasion  of  the  cranial  cavity  is  accompanied  in 
the  case  of  sinus  thrombosis  by  sudden  elevation  of  temperature,  followed  by 
a  decided  fall  in  temperature;  the  temperature  curve  becomes  irregularly 
intermittent  thereafter.  The  symptoms  of  general  sepsis  are  present.  Septic 
emboli  may  become  lodged  in  the  viscera,  particularly  in  the  lungs.  If  the  lateral 
sinus  is  the  seat  of  thrombosis,  the  latter  may  extend  into  the  internal  jugular 
vein,  with  tenderness  and  tumefaction  along  the  course  of  the  latter.  In 
cases  of  diffuse  septic  meningitis  there  is  intense  headache,  intolerance  of  light, 
constant  high  temperature,  and  nausea  and  vomiting.  The  pulse  is  generally 
rapid  when  the  meningitis  is  basilar,  which  condition  is  usually  the  case  in 
otitic  meningitis.  Local  paralyses,  particularly  those  involving  the  distribution 
of  the  third  and  sixth  nerves,  appear  early.  Rigidity  of  the  muscles  of  the 
neck  is  an  early  and  characteristic  s3aiiptom.  In  cases  of  localized  menin- 
gitis the  constitutional  symptoms  are  less  severe,  the  headache  localized,  the 
paralytic  symptoms  delayed  in  their  appearance,  and  the  vomiting,  intolerance 
of  light,  and  rigidity  of  the  muscles  of  the  neck  absent. 

Treatment. — Whether  or  not  an  aural  discharge  is  present,  free  drainage 
through  the  canal  should  be  insured  by  incising  any  bulging  segment  of  the 
drum  membrane.  This  is  followed  by  irrigation  with  boric  acid  solution 
and  the  application  of  ice,  if  the  case  is  not  advanced.  The  presence  of  the 
Streptococcus  pyogenes  in  the  discharge  constitutes  an  indication  for  im- 
mediate opening  and  drainage  of  the  mastoid,  even  in  the  absence  of  definite 
symptoms  of  mastoiditis.  The  presence  of  this  microorganism  in  the  dis- 
charge resulting  from  an  exploratory  puncture  of  the  ear  drum  likewise  indi- 
cates the  operation.  Even  in  the  absence  of  a  streptococcus  infection  efforts 
to  abort  the  attack  should  not  be  continued,  at  the  very  outside,  beyond 
forty-eight  hours  from  its  commencement.  The  mastoid  cells  should  be  freely 
opened  and  the  infected  area  exposed  by  removal  of  the  entire  cortex  and 
drainage  of  the  middle  ear  through  the  opening  secured. 

Trephining  the  Mastoid;  Antrectomy. — The  incision  commences  at  the 
top  of  the  auricle  in  the  line  of  the  hair,  and  is  curved  first  backward,  then 
backward  and  doAvnward,  and  finally  downward  and  forward  to  terminate 
at  the  posterior  part  of  the  apex  of  the  mastoid  (Fig.  347,  1  to  2).  The  in- 
cision is  carried  directly  do^■v^l  to  the  bone.  If  the  aponeurosis  of  the  sterno- 
mastoid  comes  into  view  at  the  lower  angle  of  the  incision,  it  is  to  be  detached 
from  the  bone  by  means  of  blunt  scissors,  the  instrument  hugging  the  bone 
closely  while  this  is  being  done.  In  children  the  stylomastoid  foramen,  owing 
to  the  undeveloped  condition  of  the  mastoid  process,  is  laterally  placed,  instead 
of  lying  on  the  under  surface  of  the  base  of  the  skull,  so  that  deep  dissection 
carried  below  a  point  on  a  level  with  the  middle  of  the  meatus  exposes  the 
facial  nerve  to  injury. 

The  bone  is  thoroughly  cleared;  the  auricle  is  detached  l3y  blunt  dissection, 
and,  together  with  the  skin  lining,  the  meatus  is  pushed  well  forward  and  held 


tup:  ear 


585 


by  a  retractor.  If  a  sinus  the  result  of  a  spontaneous  rupture  is  present,  this 
is  enlarged  and  followed;  it  will  generally  lead  to  the  mastoid  antrum.  If 
no  sinus  is  present,  the  upper  limit  of  the  external  auditory  canal  is  located; 
under  no  circumstances  must  the  opening  in  the  bone  bo  carried  above  the 
level  of  this  point.     The  cortex  over  the  antrum,  the  level  of  which  corresponds 


Fig.  347. — Lines  of  Incision  for  Mastoiditis,  Brain  Abscess,  and  Sinus  Thrombosis. 
1  to  2,  Incision  for  mastoid  operation;   2  to  4  and  2  to  5,  incisions  for  brain  abscess;   3,  line  of  incision  for 

sinus  thrombosis. 

with  the  upper  half  of  the  orifice  of  the  external  meatus,  is  removed  with 
the  chisel.  The  junction  of  the  antrum  with  the  middle  ear  corresponds 
with  the  posterior  half  of  the  segment  of  the  orifice  of  the  external  meatus  above 
mentioned.     The  further  application  of  the  chisel  is  made  so  as  to  deepen  the 


Fig.  348. — Mastoid  Chisels. 


opening,  a  bony  funnel  being  formed.  The  larger  pneumatic  spaces  are  soon 
opened,  and  the  antrum  reached  at  a  depth  varying  from  an  eighth  to  three- 
fourths  of  an  inch.  Occasionally  it  is  obliterated  by  hypertrophic  sclerosis. 
As  the  cancellous  structure  is  reached  the  gouge  is  substituted  for  the  chisel 
and  worked  as  much  as  possible  with  the  hand,  the  use  of  the  chisel  being 


586  THE  SURGERY  OF  THE  HEAD 

avoided.  Entrance  to  the  antrum  is  known  by  the  fact  that  a  probe,  sUghtly 
bent  at  its  tip,  passes  into  the  middle  ear.  The  antrum  and  passage  to 
the  middle  ear  are  now  thoroughly  curetted.  If  granulation  tissue  is  present 
the  curetting  should  be  carefully  proceeded  with;  this  sometimes  springs  from 
the  dura  lining  the  cerebellar  fossa  and  covering  the  sigmoid  sinus,  and  projects 
into  the  mastoid  cells.  All  pus  and  debris  being  cleared  away,  the  bony  cavity 
is  packed  with  sterile  gauze  and  the  upper  portion  of  the  wound  sutured  with 
silkworm-gut . 

Injury  to  the  lateral  sinus  is  best  avoided  by  keeping  well  forward  toward 
the  auricular  attachment,  and  above  the  level  of  the  lobe  of  the  ear.  If  the 
dura  of  the  middle  cranial  fossa  is  exposed,  the  remainder  of  the  chiseling 
must  be  done  at  a  lower  level,  in  order  to  reach  the  mastoid  antrum.  Hemor- 
rhage from  an  injury  to  the  lateral  sinus  can  be  controlled  by  tamponing  with 
iodoform  gauze,  the  operation  being  completed  by  enlarging  the  opening  in 
the  opposite  direction. 

In  children  the  mastoid  cells  are  but  imperfectly  developed,  almost  the 
entire  process  being  occupied  by  the  antrum.  Great  variations  exist  in  the 
adult  mastoid  process,  in  20  per  cent  of  which  there  is  an  absence  of  pneu- 
matic cells;  in  38  per  cent  the  opposite  condition  obtains,  i.  e.,  the  absence 
of  diploe.  In  some  cases  the  upper  half  of  the  mastoid  process  is  pneumatic, 
the  lower  half  containing  diploe. 

In  the  absence  of  the  antrum,  or  when  no  pus  is  present  in  this  cavity,  the 
apex  of  the  mastoid  and  the  vertical  group  of  cells  should  be  explored.  When 
the  latter  are  well  developed  and  become  infected,  perforation  is  liable  to  occur 
on  the  inner  side  of  the  apex,  followed  by  suppuration  in  the  digastric  fossa  and 
under  the  sternomastoid  muscle. 

In  cases  of  long-standing  discharge,  with  extensiA^e  disease  in  the  tympanum, 
and  particularly  where  previous  operations  have  failed,  the  auricle  should  be 
temporarily  detached,  and,  in  addition  to  the  outer  wall  of  the  antrum,  the 
upper  and  outer  portion  of  the  bony  meatus  and  the  remains  of  the  membrana 
tympani  and  ossicles  should  be  removed  (S  t  a  c  k  e). 

Abscess  of  the  Brain. — This  may  give  rise  to  no  characteristic  symptoms, 
except  constant  headache,  progressive  weakness  and  dullness  of  intellect,  until 
it  has  attained  sufficient  size  to  press  on  some  portion  of  the  motor  area. 
The  temperature  may  remain  normal  or  become  but  slightly  elevated.  In- 
vasion of  the  motor  tract  will  give  rise  to  definite  localizing  symptoms  in  many 
cases  (see  page  467).  It  should  be  borne  in  mind  that  two  or  more  intracranial 
complications  of  otitic  origin  may  be  present  at  the  same  time. 

Steatomas  of  the  mastoid  consist  of  epithelial  collections  in  the  cells.  They 
may  excite  hyperjDlastic  inflammation,  sclerosis,  and  obliteration  of  the 
trabeculae,  in  some  cases  converting  the  mastoid  antrum,  tympanic  cavity, 
and  external  bony  canal  into  one  cavity,  with  sclerosis  of  the  mastoid  cortex. 


THE  SALIVARY  GLANDS 

Injuries  of  the  Parotid  Gland. — ^These  may  result  from  blows,  stabs,  or 
gunshot  wounds;  they  may  also  occur  in  the  course  of  operations.  Healing 
usually  takes  place  promptly.     The  occurrence  of  a  salivary  fistula  is  generally 


THE    SALIVARY    GLANDS 


587 


preceded  by  the  accuinuUilion  of  saliva  beneath  the  suture  hue.  Pressure  on 
this,  abstinence  from  cliewing  and  talkino-,  and  a  fluid  diet  taken  in  small 
quantities,  usually  suffice  to  prevent  a  fistula.  Even  when  the  latter  occurs 
it  is  not  usually  persistent. 

Injuries  of  the  Parotid  (Stenson's)  Duct.— Fhese  usually  result  from 
sword' slashes  or  stal)  wounds,  and  occasionally  from  operation  wounds.  The 
flow  of  sali\'a  from  the  wound  usually  announces  the  nature  of  the  injury. 
This  mav  be  verified  by  passing  a  probe  from  the  normal  orifice  in 
the  mouth  to  and  out  of  the  wound  in  the  cheek.  If  the  wound  of  the 
cheek  is  a  penetrating  one  and  the  external  portion  heals,  the  centrally 
placed  divided  end  is  kept  patent  by  the  saliva  flowing  into  the  mouth.  If  the 
wound  is  nonpenetrating  and  allowed  to  heal  as  such  spontaneously,  a  salivary 
duct  fistula  is  sure  to  follow. 

Treatment. — In  order  to  prevent  a  fistula  of  Stenson's  duct  in  non- 
penetrating wounds  of  the  cheek  primary  union  must  be  secured;  the  duct 
itself  must  be  sutured  separately  with  fine  catgut.  The  sutures  should  not 
encroach  upon  the  lumen  of  the  duct.  In  penetrating  wounds  the  skin  alone  is 
sutured,  the  saliva  being  allowed  to  flow  into  the  mouth  through  the  wound 
in  the  mucous  membrane.  In  contused  and  lacerated  wounds  involving 
Stenson's  duct,  in  which  primary  union  is  improbable,  an  immediate 
communication  should  be  made  in  order  to  secure  an  internal  salivary  fistula; 
the  latter  will  serve  all  the  purposes  of  a  normal  duct. 

In  the  after-treatment  of  injury  of  the  parotid  duct  the  secretion  of  saliva 
and  movements  of  the  jaw  should  be  restricted  as  much  as  possible. 

A  permanent  fistula  of  Stenson's  duct  results  when  the  wound  heals 
with  fusion  of  the  mucous  membrane  and  skin  at  the  site  of  the  injury,  or  when 
the  peripheral  portion  of  the  duct  is  occluded  and  the  central  portion  termi- 
nates externally.  Loss  of  substance  of  the  duct  itself  is  also  sometimes  present. 
Undermining  of  the  surrounding  parts  takes  place  in  some  cases  and  the  saliva 
discharges  by  several  small  openings.  The  fistula  is  usually  situated  in  the 
buccal  division  of  the  duct.  The  diagnosis  is  generally  made  by  the  cUscharge 
of  saliva  upon  the  cheek,  and  in  some  cases  it  may  be  verified  by  probing. 

Treatment.— When  the  proximal  end  is  still  pervious,  cauterization  with 
the  solid  stick  of  nitrate  of  silver  or  the  use  of  the  actual  cautery  should 
be  tried.  If  the  peripheral  end  is  impermeable  to  probing  and  an  injec- 
tion of  a  colored  solution  from  the  oral  opening  fails  to  appear  at  the 
fistulous  opening,  a  spontaneous  cure  is  not  possible,  and  operative  measures 
must  be  resorted  to.  The  simjDlest  of  these  is  to  convert  an  external  fistula  into 
an  internal  one.  The  cheek  is  perforated  somewhat  obliquely  by  a  trocar 
passed  from  the  cavity  of  the  mouth  to  the  site  of  the  fistula.  A  small  drainage- 
tube  is  passed  along  the  canal  thus  formed,  its  inner  end  projecting  into  the 
cavity  of  the  mouth;  its  outer  end  is  cut  off  obliquely  so  as  to  receive  the  saliva, 
which  it  conducts  into  the  mouth.  The  tube  is  removed  in  about  ten  days. 
A  substitute  for  the  occluded  peripheral  portion  of  the  duct  having  been  thus 
formed,  the  fistula  either  closes  spontaneously  or  is  cauterized  or  sutured 
(K  a  u  f  m  a  n  n).  The  method  by  double  puncture  consists  in  first  excising 
the  fistula  for  half  the  thickness  of  the  cheek,  and  passing  a  silk  ligature  through 
the  remaining  portion  so  as  to  include  about  |  of  an  inch  of  tissue.  The  ligature 
is  tied  tightlv  from  the  inside  of  the  mouth.     The  included  bridge  of  tissue 


588  THE  SURGERY  OF  THE  HEAD 

sloughs  and  an  internal  opening  of  the  fistula  is  provided  (D  e  g  u  i  s  e).  The 
external  wound  is  sutured.  These  measures  failing,  the  central  end  may  be 
dissected  out  and  implanted  into  the  mucous  membrane  (Langenbeck). 
In  the  absence  of  sufficient  length  of  the  duct  to  accomplish  this  a  new  duct 
may  be  formed  from  the  mucous  membrane  (N  i  c  o  1  a  d  o  n  i,    B  r  a  u  n). 

Foreign  bodies  sometimes  find  their  way  into  the  salivary  excreting  ducts. 
A  bristle  from  a  tooth-brush,  small  fish-bones,  and  hairs  have  been  found  in 
Stenson's  duct.  Large  foreign  bodies,  such  as  the  cereals,  seeds  of  fruit, 
etc.,  are  much  more  frequently  found  in  the  submaxillary  duct.  Inflammatory 
conditions,  or,  if  the  foreign  body  is  not  forced  out,  abscesses  and  fistulas 
follow.  Sometimes  the  foreign  body  is  not  discovered  until  an  incision  is  made 
for  the  relief  of  an  abscess.  The  treatment  consists  in  removal  of  the  foreign 
body  by  forcing  it  toward  the  orifice,  or  exposing  it  by  an  incision  through  the 
mucous  membrane.  If  the  foreign  body  has  found  its  way  to  the  submaxillary 
gland,  the  latter  may  become  so  altered  by  inflammatory  conditions  as  to 
recjuire  removal. 

Salivary  Calculus. — Salivolithiasis  is  of  relatively  infrecjuent  occur- 
rence. It  occurs  most  often  between  the  ages  of  twenty  and  forty.  Men  are 
more  often  affected  than  women.  Sali^'ary  calculi  are  most  frec|uently  found 
in  Wharton's  duct,  though  they  likewise  occur  in  the  submaxillary  gland, 
in  the  sublingual  duct,  and  in  the  sublingual  gland.  The  calculi  vary  in  size 
from  a  grain  of  sand  to  a  split  pea,  or  even  a  hazelnut.  More  than  one  may  be 
present.  In  composition  they  usually  consist  of  calcium  carbonate  with  the 
addition  of  calcium  phosphate,  soluble  salts,  and  organic  matter.  The  essential 
pathologic  factors  in  the  etiology  of  salivar}^  calculi  are  foreign  bodies  (particles 
of  food,  fragments  of  tartar  from  the  teeth,  etc.)  and  bacterial  infection. 

The  symptoms  vary  with  the  size  of  the  calculus,  its  location,  and  the 
occurrence  of  suppuration.  In  the  absence  of  the  latter  but  slight  discomfort 
may  be  present.  Retention  of  saliva  lasting  for  several  hours  after  a  meal, 
accompanied  by  pain  and  discomfort  ("salivary  colic"),  is  characteristic  of  a 
calculus  in  Wharton's  duct.  A  hard  nodule  in  the  floor  of  the  mouth, 
with  difficulty  in  chewing,  swallowing,  and  speaking,  is  usually  present.  If 
suppuration  occurs,  the  abscess  frequently  discharges  into  the  mouth,  the 
calculus  escaping  at  the  same  time ;  the  latter  is  rarel}^  discharged  through  the 
normal  orifice  of  the  duct.  The  stone  may  give  rise  to  pressure  necrosis  and 
escape  through  the  opening  thus  made.  With  the  occurrence  of  suppuration 
the  corresponding  gland  becomes  infected,  giving  rise  to  a  j^ainful  swallowing. 
Phlegmonous  cellulitis  of  the  neck,  resembling  L  u  d  w  i  g  '  s  angina,  may 
supervene.  Spontaneous  external  discharge  of  supi^urative  collections  may 
lead  to  salivary  fistula.  The  diagnosis  may  often  be  confirmed  by  probing  the 
duct.  The  affection  is  to  be  differentiated  from  inflammation  of  the  duct,  from 
alveolar  abscess,  particularly  in  cases  in  which  the  abscess  develops  about  the 
submaxillary  gland,  and  from  syiDhilitic  and  tuberculous  disease,  actinomycosis, 
and  mahgnant  disease.     The  a;-ray  may  be  useful  in  the  diagnosis. 

The  treatment  consists  in  evacuation  of  the  abscess,  removal  of  the  calculus, 
and,  in  the  case  of  the  submaxillarj'^  and  sublingual  gland,  the  removal  of  these 
if  a  number  of  calculi  are  present  and  are  difficult  to  remove,  or  the  gland  is  the 
seat  of  miliary  abscesses.  Simple  infection  of  the  gland  is  not  an  indication  for 
its  removal.     When  the  stone  is  situated  in  the  duct,  it  should  be  removed 


THE    SALIVARY    GLANDS  589 

thnnio'h  the  mouth;  if  in  one  of  the  siilivary  glands,  it  must  he  attacked 
from  the  outsid{\ 

Inflammation  of  the  Salivary  Gland  (Sialadenitis). — This  is  usually 
caused  by  infections  from  the  cavity  of  the  m(jutli.  Acute  i^rimary  inflam- 
mation of  the  salivary  glands  is  rare  with  the  exception  of  the  acute  epidemic 
form  (mumps).  This  affection  derives  a  surgical  importance  from  the  orchitis 
which  ckn'clops  as  a  complication,  and  for  which  no  satisfactory  explanation 
has  been  given.  Atrophy  of  the  testicle  occurs  in  about  one-third  of  the  cases 
(Kocher).  Abscess  occasionally  forms.  Oophoritis,  mastitis,  vulvovagin- 
itis, prostatitis,  and  cystitis  are  other  complications  of  surgical  interest.  Acute 
secondary  sialadenitis  results  from  foreign  bodies,  calculi,  and  septic  con- 
ditions following  injuries.  It  is  not  an  infrecjuent  complication  of  typhus;  it 
also  occurs  in  other  infectious  febrile  states  (scarlet  fever,  pneumonia,  variola, 
pyemia,  septicopyemia,  etc.).  It  likewise  develops  after  operations,  particularly 
abdominal  section  (not  necessarily  operations  on  the  ovaries,  as  was  formerly 
believed).  Here,  as  in  the  case  of  the  febrile  conditions,  it  is  also  due,  in  all 
probability,  to  infection  from  the  mouth,  since  it  has  been  shown  (P  a  w  1  o  w) 
that,  after  abdominal  section,  as  in  the  febrile  state,  there  is  a  cessation  or 
diminution  of  the  salivary  secretion.  To  this  is  to  be  added,  as  increasing  the 
locus  minoris  resistentiae,  the  drvness  of  the  mucous  membrane  of  the  mouth. 

The  symptoms  of  parotitis  are  fever,  swelling  of  the  gland,  radiating  pains, 
and  tenderness.  The  sw^elling  is  first  seen  below  the  angle  of  the  jaw,  but 
finally  extends  from  the  middle  of  the  cheek  to  the  mastoid  and  lower  temporal 
regions.  The  lobule  of  the  ear  becomes  prominent  and  is  elevated ;  the  appear- 
ance is  characteristic.  The  parts  are  intensely  tender,  especially  when  attempts 
are  made  to  move  the  jaw,  and  the  radiating  pains  become  intense.  The  skin 
becomes  red  and  edematous  and  the  superficial  veins  are  dilated.  The  hearing 
may  become  affected  by  compression  of  the  external  auditory  canal.  If  the 
symptoms  continue  to  increase  beyond  the  third  or  fourth  day,  suppuration 
will  probably  occur.  Extensive  abscess  formation  may  be  present  without 
palpable  fluctuation,  on  account  of  the  unyielding  overlying  fascia.  Perfora- 
tion may  occur  into  the  external  auditory  canal  and  purulent  otitis  media 
result.  Burrowing  may  take  place  behind  the  pharynx  and  esophagus  and 
into  the  mediastinum,  rupture  finally  taking  place  into  the  air-passages.  In- 
fection may  travel  along  the  vessels  and  nerves  and  reach  the  interior  of  the 
cranium.  Cerebral  complications  may  also  arise  through  the  medium  of  venous 
thrombi.     Thrombosis  of  the  jugular  vein  and  sigmoid  sinus  may  occur. 

Involvement  of  the  submaxillary  gland  is  comparatively  rare,  and  ex- 
tensive suppuration  here  is  the  exception  .rather  than  the  rule.  ^^Tien  this 
does  occur,  it  resembles  in  its  course  L  u  d  w  i  g  '  s  angina. 

Sialadenitis  affecting  the  submaxillary  and  sublingual  glands  occurs  in 
nursing  children.  Suppuration  is  the  rule,  the  pus  escaping  through  the  ex- 
cretory ducts  and  breaking  through  the  skin  and  escaping  externally. 

The  treatment  of  inflammation  of  the  salivary  glands  consists  in  prophy- 
lactic cleansing  of  the  mouth  of  a  patient  who  has  undergone  an  operation, 
or  of  one  seriously  ill  with  a  febrile  affection.  The  boric  solution,  with  the  addi- 
tion of  thymol,  gaultheria,  and  tincture  of  myrrh,  applied  with  gauze,  is  useful. 
With  the  development  of  the  disease  ice  is  to  ]3e  applied  to  the  parts  for  two  or 
three  days.     If  no  improvement  follows  this  treatment,  and  the  ^•iolent  symp- 


590  THE  SURGERY  OF  THE  HEAD 

toms  persist,  a  free  incision  should  be  made  through  the  fascia  and  the  gland 
further  exposed  b}^  blunt  separation  with  a  grooved  director,  or  the  blunt 
blades  of  an  artery  clamp.  In  making  the  incision  in  the  case  of  the  parotid 
gland  the  facial  nerve  is  to  be  avoided.  Diffuse  suppuration  and  perhaps 
necrosis  may  be  revealed.  The  parts  are  to  be  curetted,  carefully  cleansed, 
and  a  drainage-tube  and  an  iodoform  gauze  tampon  introduced.  Early 
operative  interference,  in  these  cases,  gives  the  best  results. 

The  sialadenitis  of  nursing  children  is  to  be  treated  by  incision  and  drainage. 

The  "inflammatory  tumor"  of  Kiittner  is  a  chronic  interstitial  in- 
flammation of  the  submaxillary  salivary  gland.  The  gland  increases  in  size 
to  a  hen's  egg,  or  becomes  larger,  and  is  more  or  less  adherent.  Tenderness 
is  not  marked.  The  swelling  is  difficult  of  difTerentiation  from  malignant 
tumors  occurring  in  this  region,  and  for  this  reason,  as  well  as  the  fact  that 
this  tumor  tends  to  extend  to  the  surrounding  tissues,  excision  is  advisable. 

Inflammation  of  the  principal  excretory  ducts  of  the  salivary  glands  (sial= 
odochitis)  has  been  observed  in  the  duct  of  the  parotid  more  frequently 
than  in  Wharton's  duct.  Injuries  and  carious  teeth  are  said  to  be  the 
causes.  The  chief  symptoms  are  acute  retention  of  saliva,  the  formation 
of  a  salivary  tumor,  with  cessation  of  the  latter  coincidental  with  an  increased 
flow  of  saliva  as  the  obstruction  is  overcome.  The  retention  is  clue  to  a  flbrin- 
ous  plug.  The  orifice  of  the  duct  is  red  and  projecting,  and  pressure  along  its 
course  will  express  a  drop  of  pus  or  a  fibrinous  plug.  A  permanent  dilatation 
of  tlifi  duct  may  follow  and  the  gland  itself  may  become  involved.  The  treat- 
ment should  be  primarily  directed  to  the  removal  of  the  cause.  The  occa- 
sional passage  of  a  probe  and  the  injection  of  an  antiseptic  solution  afford 
relief.  The  disease  is  not  usually  amenable  to  curative  treatment  except  by 
the  operation  of  splitting  up  the  duct,  which  should  be  performed  when  the 
attacks  of  retention  are  painful  and  frecjuent. 

TUMORS  OF  THE  PAROTID  AND   SUBMAXILLARY  GLANDS 
In  addition  to  salivary  cysts,  chondroma,  adenoma,  and  sarcoma,   or 
combmations  of  these,  are  observed.     Those  of  the  parotid  gland  are  the  most 
frequent. 

Chondroma. — The  cartilage  of  the  first  branchial  arch  lies  at  the  site  of 
the  subsecjuently  developed  parotid,  and  fetal  cartilaginous  structure  is  inclosed 
during  the  formation  of  the  gland  (L  ii  c  k  e  ,  Cohnheim).  Chondroma 
of  the  submaxillary  gland  results  from  proximity  of  the  second  branchial  arch. 
These  tumors  are  globular  in  shape  and  present  nodulated  surfaces.  Their 
growth  is  very  slow  and  painless.  After  being  in  existence  for  years  they  may 
take  on  rapid  growth,  the  tumor  being  thus  converted  into  an  adenosarcoma; 
simultaneously  the  growth  softens  and  becomes  the  seat  of  pain.  After  attain- 
ing a  considerable  size  the  tumor  breaks  down,  with  ulceration  of  the  surface 
and  hemorrhage.  The  branches  of  the  seventh  nerve  become  involved  in  the 
growi^h  and  facial  paralysis  occurs.  The  patient  dies  either  from  exhaustion 
from  repeated  hemorrhages  or  from  septicemia. 

Sarcoma  of  the  Parotid  Gland. — In  all  probability  many  of  the  growths 
in  this  region  that  were  formerly  described  as  sarcomas  sprang  from  the  lymph- 
atic vessels  as  endotheliomas.  Sarcomas  appear  as  oval  shaped,  smooth,  and 
elastic  swellings.     When  composed  of  immature  hyaline  cartilage  (chondrifying; 


THE    SALIVARY    GLANDS  591 

sarcoma)  they  are  of  slow  <rro\vth  and  seldom  attain  a  large  size.  They  may  be 
of  tlie  larger  and  more  rapidly  gro^\•ing  spindle-celled  variety,  with  some 
glandular  and  more  or  less  chondral  tissue  present.  The  surrounding  structures, 
including  the  skin,  are  rapidly  involved,  the  facial  nerve  implicated,  and  the 
pharynx  encroached  upon.  Myxomatous  changes  occur,  A\ith  the  formation  of 
semifluctiuiting  spaces.  Dissemination  is  not  common.  Death  takes  place 
from  interference  with  swallowing  or  from  hemorrhage  following  ulceration  of 
some  large  vessel  in  the  neck. 

Chondrifying  sarcoma  may  also  occur  in  the  submaxillary  gland,  though 
less  frequently  than  in  the  parotid.  It  may  occur  at  all  ages,  is  of  slo\\-  growth, 
seldom  attains  a  large  size,  and,  as  a  rule,  is  found  distinctly  encapsulated. 

Chondrifying  sarcoma  affecting  the  salivary  glands  may  grow  rapidly  and 
destroy  life  in  less  than  a  year,  or  it  may  remain  stationary  for  many  years  and 
then  suddenly  take  on  an  exceedingly  malignant  character. 

Both  adenoma  and  adenosarcoma  may  arise  from  the  glandular  tissue 
independently  of  chondroma.  The  differential  diagnosis  between  adenoma 
and  sarcoma  is  sometimes  difficult.  Generally,  however,  sarcoma  presents  an 
evenly  globular  surface  and  adenoma  a  nodulated  surface.  Tumors  removed 
from  the  parotid  have  shown  sarcoma  in  one  locality,  adenoma  in  another,  and 
myxoma  or  chondroma  in  still  another.  Cystic  formations  from  obstruction  of 
the  gland  ducts  have  also  been  present  in  the  same  gland.  All  parotid  tumors 
generally  grow  from  the  middle  portion  of  the  gland  just  behind  the  ramus 
of  the  jaw  and  proj ect  forward.  Those  of  the  submaxillary  gland  are  rarer,  and 
may  easily  be  mistaken  for  diseased  lymphatic  glands.  They  may  be  distin- 
guished by  palpation ;  those  forming  the  mass  of  the  lymphatic  glands  are 
usuall}'  separable,  while  tumors  of  the  submaxillary  gland  proper  form  uniform 
masses. 

The  treatment  of  these  tumors  is  extirpation.  Small  chondromas  may 
frequently  be  "shelled"  out  without  inflicting  much  injury  on  the  gland. 
In  case  of  large  tumors,  particularly  in  adenoma  and  sarcoma,  extirpation 
of  the  entire  gland  is  demanded.  In  the  case  of  the  parotid  that  portion  which 
lies  behind  the  auricle  and  passes  deeply  to  the  base  of  the  skull  is  usuallv  left 
behind  because  of  the  impossibility  of  its  removal. 

In  extirpation  of  the  parotid  preliminary  ligation  of  the  common  carotid 
is  scarcel}'  necessary,  though  extreme  care  must  be  exercised  in  order  to  avoid 
injury  to  both  its  external  and  its  internal  branches.  If  there  is  a  suspicion  that 
the  growth  involves  one  of  these,  a  provisional  ligature  may  be  placed  ready 
for  tying  in  an  emergency.  The  facial,  temporal,  and  posterior  auricular  arteries 
may  be  ligated  if  injured.  Special  care  is  required  in  enucleating  that  portion 
of  the  growth  Avhich  lies  on  the  internal  carotid  artery  and  jugular  vein.  The 
branches  of  the  facial  nerve  are  almost  invariably  and  unavoidably  sacrificed 
in  complete  extirpation  of  the  parotid.     Permanent  facial  paralysis  results. 

Extirpation  of  the  submaxillary  gland  is  comparatively  easy  of  per- 
formance.    The  facial  artery  is  severed,  but  is  easily  secured. 

Telangiectases  of  the  parotid  of  congenital  origin  are  sometimes  observed 
in  infants.  They  are  usually  associated  with  angiomatous  conditions  in  the 
neighborhood.  When  of  rapid  growth  and  strongly  pulsating,  they  demand 
extirpation. 

Ranula. — This  is  a  cystic  tumor  situated  beneath  the  tongue.     The  growth 


592 


THE    SURGERY    OF   THE    HEAD 


usualh'  commences  on  one  side  of  the  frenum;  as  it  increases  in  size  it  extends 
across  to  the  opposite  side.  Rareh"  these  tumors  are  obser\'ed  commenc- 
ing in  the  median  line,  in  whicli  case  they  have  their  origin  in  the  glandula 
incisiva.  In  the  case  of  large  cysts  the  floor  of  the  mouth  and  the  under 
surface  of  the  tongue  are  invaded ;  the  former  is  crowded  doAATiward  until  the 
tumor  appears  I^eneath  the  chin,  -while  the  latter  is  crowded  upward  so  as  to 
cause  mechanic  interference  with  speech  and  mastication. 

Ranula  may  have  its  origin  in  the  duct  of  one  of  the  glands  of  Bochdalek, 
or  as  a  retention  c}-st  arising  from  pressure  of  the  inflammatorv''  products  of  a 
diseased  sublingual  gland  upon  one  or  more  of  its  secretory  ducts.  The  cyst  is 
usually  unicellular,  with  viscid  contents.  The  cyst  growth  may  invade  the 
mylohyoid  muscle. 

The  cyst  presents  itself  as  a  rounded  tumor  of  a  bluish-gray  or  a  grayish-red 

color,  occupying  the  space  be- 
tween the  frenum  and  the  inner 
margin  of  the  lower  jaw  (Fig. 
349).  It  may  occur  at  any 
period  of  life  and  is  some- 
times congenital.  It  is  usually 
slowly  but  steadily  progressive 
in  its  growth;  occasionally  a 
small  and  perhaps  unnoticed 
ranula  may  increase  suddenly 
in  size  as  a  result  of  some  irrita- 
tion (acute  ranula).  Spontan- 
eous rupture  of  the  cyst  wall 
sometimes  occurs  in  the  larger 
growths.  This,  like  simple 
puncture,  gives  but  tempor- 
ary relief.  The  opening  heals 
rapidly  and  the  cyst  cavity 
refills.  As  a  rare  circumstance 
infection  and  sloughing  of  the 
floor  of  the  mouth  ma}'  occur 
in  ranula. 
In  the  differential  diagnosis  the  following  are  to  be  excluded:  (1)  Tumors 
of  the  sublingual  gland  itself.  These  are  usually  solid  and  of  rare  occurrence. 
(2)  Lipomas  of  the  floor  of  the  mouth.  These  lack  the  color  of  ranula,  and 
the  greenish  hue  of  the  fatty  tissue  is  usually  to  be  distinguished  beneath  the 
attenuated  mucous  membrane.  The  sense  of  fluctuation  obtained  by  palpating 
the  ranula  between  the  fingers  is  absent  in  the  case  of  lipoma.  (3)  Sublingual 
dermoids.  These  are  connected  with  either  the  lower  jaw  or  the  hyoid  bone, 
but  these  connections  are  not  usually  to  be  made  out  except  upon  dissection. 
^4)  Cystic  dilatation  of  Wharton's  duct.  Here  the  cluct  is  almost  always 
occluded  at  its  point  of  exit,  while  in  ranula  the  duct  can  be  demonstrated 
as  pervious.  The  cylindriform  swelling  differs  from  the  rounded  up  projection 
of  a  ranula.  Cystic  dilatation  of  the  duct  is  usually  accompanied  b}^  enlarge- 
ment of  the  submaxillar}'  salivary  gland,  and,  when  due  to  an  inflammatory 
condition  or  the  presence  of  a  salivary  calculus,  by  other  and  characteristic 
symptoms. 


Fig.  349.— Ranula. 


THE    SAIJVAItV    OLAXDS 


593 


In    ho  ca,so  .,1    ho  larger  growths  the  latter  will  l.o  found  to  have  folloM'ocl  the 
prolongations  ot  tho  sublingual  gland  into  the  mylohyoid  muscle  (M  ores    in) 
m  which  case  the  gland  will  likewise  require  remo\-al.     In  the  small  growths 

he  cyst  can  usually  be  shelled  out  from  the  floor  of  the  mouth  by  blSnt Ts! 
section  after  incision  of  the  mucous  membrane.  In  case  the  cyst  wall  c^mnot 
be  entirely  reinoved,  as  much  as  possible  should  bo  excised,  the  cavi^  pX 
with  gauze,  and  obliteration  further  favored  bv  breaking  up  from  time  to  t  me 
the  adhesions  which  tend  to  form  between  the  edges  of  th^  opening.  Even  a  "r 
complete  enucleation  of  the  cyst  it  may  be  found  that  a  swelling  still  e4ts  in 
the  submental  region,  due  to  the  continued  presence  of  a  pathologic  process 
m  the  gland  Itself  underlying  the  original  production  of  the  ranula  Tnde 
these  circumstances,  and  in  the  case  of  larger  tumors  as  a  rule,  the  more  radical 

toi^  Zt         '  '",  r  ^'"/  '°'  ""^  ''''  ^^^^^^^'  -blingual  gland,  and  What 
tons  duct  removed  through  an  external  incision  made  parallel  to  the  inner 
edge  of  the  lower  jaw  and  the  separated  fibers  of  the  mylohyoid  muscle      iJ 
he  mucous  membrane  in  the  floor  of  the  mouth  is  adherent  \o  the  ranula 
should  be  removed  as  wtII.  ^^nma,  it 

Congenital  dermoid  cysts  in  the  floor  of  the  mouth  are  to  be  excised 
m  the  same  manner  as  ranula.  The  operation  is  somewhat  more  dX  ilt 
ad/rclMl"S  ""  """'  "'  '''  ''°"'  attachments  of  the  sac  wall  to  th 


SECTION  XV 
SURGERY  OF  THE  NECK 

THE  LARYNX,  TRACHEA,  AND  HYOID  BONE 

Subcutaneous  injuries  of  the  larynx  and  trachea  are  rare  in  children 
and  young  adults,  owing  to  the  elasticity  of  the  parts.  Later  in  life  the  carti- 
laginous walls  become  more  rigid  and  inelastic,  owing  to  partial  calcification 
and  ossification,  and  hence  give  way  more  easily. 

Fracture  of  the  Thyroid  Cartilages. — This  is  usually  due  to  a 
grasp  of  the  fist,  the  pressure  being  exercised  in  such  a  manner  as  to  injure 
particularly  the  thyroid  cartilages,  either  one  of  which,  or  both,  may  suffer. 
The  line  of  fracture  is  generally  oblic^ue;  the  fragments  are  displaced  tempo- 
rarily and  the  glottic  opening  closed.  When  the  grasp  is  relaxed,  the  frag- 
ments usually  spring  back  in  place  and  the  glottis  is  free.  When  the  mucous 
membrane  is  torn,  emphysema  of  the  neck  may  occur.  The  diagnosis  rests 
on  the  occurrence  of  extravasation  of  blood  in  the  neighborhood  and  extreme 
tenderness  at  the  point  of  injury.  Crepitation  is  not  usually  obtained,  and 
when  present  it  cannot  be  differentiated  from  the  sounds  that  occur  when  an 
uninjured  larynx  is  moved  against  the  vertebral  column.  Laryngoscopic 
examination  wdll  reveal  the  presence  of  submucous  hemorrhage,  and,  in 
case  the  line  of  separation  approaches  the  anterior  insertion  of  the  vocal  cords, 
the  form  of  the  glottis  will  be  changed. 

Life  may  be  threatened  by  a  steady  increase  of  the  submucous  hemorrhage 
or  hematoma;  symptoms  of  obstructed  breathing  wiU  give  warning  of  the 
threatening  danger.  Secondary  edema  of  the  parts  may  also  threaten  life. 
The  rapidity  of  the  occurrence  of  either  of  these  is  sometimes  so  great  as  to 
destroy  the  patient  before  surgical  help  can  be  obtained,  and  for  this  reason 
it  has  been  suggested  to  perform  a  preventive  tracheotomy  in  all  cases  of 
fracture  of  the  larj-nx,  when  the  diagnosis  is  assured.  In  doubtful  cases  the 
patient  should  be  carefully  watched  for  obstructive  symptoms.  In  the  rare 
cases  in  which  a  fragment  is  permanently  displaced,  tracheotomy  followed 
by  thyrotomy,  for  the  purpose  of  restoring  the  normal  shape  of  the  glottis 
by  relieving  the  pressure,  should  be  performed. 

Injuries  from  burning  or  cauterization  are  rare,  and  when  present 
are  due  to  the  inhalation  of  burning  or  corrosive  fluids.  Tracheotomy  is  also- 
here  indicated. 

Fractures  of  the  Hyoid  Bone. — These  are  verv^  rare.  Disturbances, 
of  deglutition  may  result  from  the  presence  of  a  displaced  cornua  beneath  the 
mucous  membrane  of  the  phar\mx  (Valsalva's  dysphagia).  The  cornua 
may  be  replaced  after  incision  or  it  may  be  extirpated. 

Wounds  of  the  Air=passages. — Gunshot  injuries  are  infrequent. 
In  case  the  blood  does  not  find  free  exit  through  the  wound,  or  is  coughed  out 

594 


Tin:    LAKVXX,    TKAt'IIEA,    AND    HYOID    BONE  595 

as  it  flows  into  the  larynx  or  trachea,  suffocation  may  ensue.     Immediate 
tracheotomy  is  indicated  in  this  chiss  of  injuries. 

Suicide  wounds  of  the  larynx  and  trachea  are  more  common.  The 
relatne  absence  of  danger  to  life  in  this  class  of  injuries  is  well  known  In 
these  gaping  incised  wounds  it  is  better  to  leave  the  wound  to  heal  by  granu- 
lation than  to  attempt  complete  suturing,  on  account  of  the  dangers  of  emphy- 
s(>ma  of  the  neck.  A  compromise  course  which  assists  materially  in  shorten- 
mg  the  healing  process  is  to  perform  a  low  tracheotomy  and  suture  the  original 
wound  at  the  angles.  The  wound  may  traverse  the  tissues  so  as  to  seA'er  the 
attachments  of  the  epiglottis  and  open  the  pharynx,  in  which  case  the  patients 
must  be  fed  by  means  of  an  esophageal  tube.  Wounds  of  the  larynx  and 
trachea  may  lead  to  cicatricial  stenosis  and  require  the  permanent  use  of  a 
tracheal  cannula. 

In  stab  wounds  the  weapon  may  penetrate  the  posterior  wall  of  the  upper 
air-passages,  when  the  esophagus  will  also  be  opened.  In  punctured  wounds 
emphysema  is  likely  to  occur  and  may  be  prevented  or  remedied  by  tracheot- 
omy below  the  point  of  puncture.  The  emphysema  soon  disappears  by 
resorption  of  the  infiltrated  air. 

Rupture  of  the  tracheal  mucous  membrane  with  infiltration  of  air  into 
the  connective  tissue  of  the  neck  sometimes  occurs  from  forcible  shouting 
efforts.  When  this  forms  a  saclike  cavity  on  the  side  or  in  front  of  the  trachea'' 
it  may  simulate  goiter.  ' 

Foreign  Bodies  in  the  Air=passages.— Irregular  or  spasmodic  action 
of  the  muscles  engaged  in  the  act  of  swallowing  is  the  usual  cause  of 
passage  of  portions  of  food,  and  particularly  fluids,  into  the  trachea.  The 
sensitiveness  of  the  glottis  is  such  as  to  impel  an  act  of  coughing  as  soon  as 
fluid  comes  in  contact  with  that  structure,  which  results  in  the  removal  of  the 
latter.  Suffocation  may  result  from  the  passage  of  vomited  matters  as  well 
as  of  artificial  teeth  in  surgical  anesthesia. 

The  space  between  the  true  vocal  cords  and  the  ventricular  bands  is  a 
favorite  place  for  the  lodgment  of  pointed  and  angular  foreign  bodies,  such 
as  pins,  fish-bones,  etc.  These  may  be  removed  by  means  of  cur^^ed  forceps 
with  the  aid  of  the  laryngoscope.  The  further  progress  of  the  foreign  body 
tends  in  the  direction  of  the  right  bronchus,  from  the  fact  that  the  latter  is 
almost  a  continuation  of  the  trachea  and  has  a  larger  lumen. 

Small  and  smooth  foreign  bodies  taken  in  the  mouth  by  children  at  play 
sometimes  pass  into  the  larynx  and  produce  suffocative  svmptoms.  These 
shortly  disappear  on  account  of  the  forcing  of  the  foreign  body  either  upward 
into  the  ventricle  of  the  larynx  or  dovnwa'rd  into  the  trachea."  In  the  former 
situation  its  presence  may  be  easily  recognized  by  means  of  the  laryngoscope, 
and  sometimes  even  in  the  latter  situation,  where,  if  not  attached,  \t  may  be 
seen  moving  up  and  down  with  each  act  of  respiration.  Auscultation  over 
the  trachea  will  also  give  the  physical  signs  of  obstructed  entrance  and  exit 
of  air  m  case  a  foreign  body  with  rough  surface  has  lodged  against  the 
tracheal  wall.  In  case  the  foreign  body  has  lodged  in  a  bronchus,  the 
respiratory  movements  of  that  side  of  the  chest  are  lessened,  and'  the 
respiratory  murmur  found,  on  auscultation,  to  be  notablv  weakened  or 
absent  altogether.  The  pectoral  fremitus  is  also  lessened.  Interlobular 
emphysema,  which  may  extend  to  the  neck,  has  also  been  observed. 


596  SURGERY   OF  THE   NECK 

Treatment. — As  soon  as  it  is  positively  determined  that  the  foreign  body 
has  passed  beyond  the  glottis  a  tracheotomy  must  be  ]:)erformed.  If  the  body 
is  not  coughed  out  through  the  tracheal  opening,  the  latter  will  afford  facilities 
for  its  subsecjuent  dislodgment.  If  this  fails,  aTrendelenburg  cannula 
may  be  introduced,  the  thyroid  cartilages  split  (thyrotomy),  and  the  foreign 
bocly  removed.  Or,  the  patient  being  guarded  against  further  downward 
passage  of  the  foreign  body  by  the  presence  of  the  cannula,  attempts  may  be 
made  to  remove  it  through  the  glottic  opening  with  the  aid  of  the  lar}'ngoscope. 

If  the  lodgment  is  in  one  of  the  bronchial  tubes,  the  case  becomes  greatly 
complicated.  Here  the  tracheotomy  wound  will  serve  to  facilitate  the  ex- 
ploration, and  may  also  serve  to  increase  the  ease  of  expulsion  later  on,  should 
the  foreign  body  become  loosened  by  suppurative  changes  in  the  immediately 
adjoining  tissues.  If  the  foreign  body  chances  to  be  metallic  and  hollow,  as, 
for  instance,  a  detached  tracheal  cannula,  its  presence  and  location  may  be 
determined  by  means  of  the  telephone  probe.  Its  removal  will  be  greatly 
facilitated  once  its  exact  location  is  determined.  With  the  tracheotomy  wound 
located  as  low  as  possible,  the  foreign  body  may  sometimes  be  reached  with 
properly  bent  forceps.  I  once  succeeded  in  thus  locating  and  removing  a 
tracheal  cannula  which  had  become  loosened  from  its  shield  and  had  passed 
into  the  left  primary  bronchus.  Finally,  efforts  at  loosening  and  other 
measures  failing,  an  attempt  may  be  made  to  reach  the  site  of  the  incarcerated 
foreign  body,  if  in  a  primary  bronchus,  by  means  of  resection  of  the  chest  wall 
behind.  This  operation  was  devised  by  me  and  carried  out  under  my  direction 
in  the  dead-house  at  St.  Mary's  Hospital  by  Dr.  E  .  Arthur  Parker, 
who  was  at  that  time  my  House  Surgeon,  on  May  27,  1891.  The  experimental 
procedure  demonstrated  that  the  operation  could  be  carried  out  without  injury 
to  important  structures.*  Gauze  tamponade,  without  suture  of  the  bronchus, 
tube  drainage,  and  partial  closure  of  the  external  wound  meet  the  indications 
in  the  after-treatment. 

Failure  to  remove  the  foreign  body  is  usually  followed  by  grave  septic 
pneumonia  in  the  respective  portions  of  the  lungs.  Angular  shaped  or  pointed 
objects  may  perforate  a  bronchus  and  cause  suppurative  mediastinitis. 
Perforation  of  the  aorta  or  of  the  pulmonary  artery  may  occur.  The  esophagus 
may  be  invaded ;  passage  of  food  into  the  air-passages  and  fatal  pleuropneu- 
monia follow. 

Laryngoscopy. — The  reciuisites  for  an  ordinary  examination  of  the  in- 
terior of  the  larynx  are  (1)  a  good  light,  the  strong  white  light  of  a  kerosene 
lamp  answering  the  purpose  admirably;  (2)  a  perforated  concave  reflector  three 
to  four  inches  in  diameter  with  a  focal  distance  of  from  six  to  eight  inches,  and 
an  apparatus  to  secure  it  to  the  head  (Fig.  350);  (3)  laryngoscopic  mirrors  of 
v8.rious  sizes  (Fig.  351). 

*  At  my  request,  Dr.  Parker  has  furnished  me  with  the  follomng  report  of 
the  experimental  procedure  from  notes  and  a  sketch  made  at  the  time:  A  foreign  body 
(a  cork  from  a  medicine  bottle)  was  introduced  through  a  tracheotomy  opening  and  forced 
into  the  left  bronchus  by  means  of  a  stout  wire.  The  left  arm  was  drawn  forward  to  gi^-e 
additional  space  between  the  scapula  and  the  spine.  A  "double  door"  incision  was  made 
to  include  the  second,  third,  and  fourth  ril^s,  and  the  latter  divided  as  near  the  spine  as  pos- 
sible, and  near  the  posterior  border  of  the  scapula.  The  included  sections  of  ribs  were  re- 
moved and  the  pleura  incised.  A  tenaculum  was  passed  through  the  wall  of  the  bronchus 
and  into  the  cork,  thus  fixing  the  latter  securely.  An  incision  was  then  made  over  the 
cork  in  the  lone;  diameter  of  the  bronchus,  and  the  cork  easily  extracted. 


THE    LAllY.VX,    TUACHKA,    AND    llVoJI)    BONE 


597 


The  room  is  darkenod  aiul  the  patient  .seated  witli  the  lamp  on  a  table  and 
behind  his  left  shoulder.     'J'he  operator  places  the  reflector  on  his  head  and 


Fig.  350. — Laryngoscopic  Head  Band  and  Reflector. 

adjusts  the  latter  so  that  the  perforation  in  its  center,  his  own  eye,  and  the 
back  of  the  patient's  larynx  are  in  line  (Fig.  352).     In  Collin's  reflector 


Fig.  351. — Laryngoscopic  Mirror. 


(Fig.  353)  both  eyes  are  emplo^'ed.     The  surgeon  draws  the  tongue  forward  by 
grasping  its  tip,  slipping  being  prevented  by  the  interposition  of  a  single  thick- 


FiG.  352. — Laryngoscopic  Ex.a.mination. 
The  reflector  and  mirror  in  position. 


ness  of  a  coarse  napkin  or  towel.     The  image  mirror  must  be  warmed  Ijefore 
introduction  to  prevent  condensation  of  moisture  from  the  patient's  breath  on 


598 


SURGERY    OF   THE    NECK 


Fig.  353. — Collin's  Electric  Light  Reflector. 


its  surface,  and  consequent  blurring.  The  fauces  may  be  advantageously 
sprayed  with  a  10  to  20  per  cent  solution  of  cocain  to  overcome  troublesome 
irritability  of  the  parts.     The  rays  of  light  are  caught  on  the  reflector  from  the 

lamp  behind  the  patient's  shoul- 
der and  reflected  on  the  surface 
of  the  mirror  held  over  the  glottic 
opening,  in  which  is  seen  the  re- 
versed reflected  image  of  the  parts 
below  (Fig.  354).  When  the  pa- 
tient makes  such  sounds  as  "ah" 
and  "air"  the  vocal  cords  are 
readily  seen  in  different  posi- 
tions, and  upon  deep  and  forced 
inspiratory  efforts  the  tracheal 
rings,  and  under  favorable  cir- 
cumstances the  bifurcation  of  the 
trachea,  are  brought  into  view. 

Inflammatory  Obstruc= 
tions  of  the  Larynx  and  Tra= 
chea. — Catarrhal  inflammation 
in  its  severest  form  may  lead  to 
serious  obstruction  through  ser- 
ous infiltration  of  the  submucous 
connective  tissue,  and  demand 
tracheotomy.  The  mucous  mem- 
brane covering  the  false  vocal  cords  and  ar^^epigiottic  ligaments  are  most  fre- 
quently the  site  of  this  submucous  infiltration.  Two  roll-hke  masses  result 
from  edema  of  the  long  mucous  folds  of 
the  latter,  which  upon  inspiration  are 
sucked  in  toward  the  central  portion  of 
the  glottis  and  obstruct  it.  They  can  be 
felt  by  palpation  from  the  mouth.  There 
is  no  obstruction  to  expiration.  Edema 
of  the  glottis  may  result  from  an  exten- 
sion of  traumatic  inflammatory  edema  of 
the  pharyngeal  mucous  membrane.  The 
treatment  consists  in  scarification  of  the 
edematous  tissue,  and  finally  trache- 
otomy. 

Diphtheritic  inflammation  produces 
stenosis  of  the  larynx  and  trachea  by 
both  submucous  infiltration  and  pseudo- 
membranous deposit.  The  glottis  itself, 
the  narroAvest  portion  of  the  air-pas- 
sages, is  the  part  which  when  encroached 
upon  demands  operative  measures  of  re- 
lief. In  these  cases  intubation  of  the  larynx  is  frequently  performed 
with  benefit  (O'Dwyer).  The  percentage  of  recoveries  is  about 
the    same    as    in   tracheotomy,    with    the    added     advantage    that    there    is 


Fig.    354. — The    Larynx    as  seen   in   the 

Laryngoscopic  Mirror. 

The  illustration  shows  the  parts  larger  than 

normal  in  order  to  bring  out  the  details. 


THE    LARYXX,    TRACHKA,    AM)    IIVOII)    JJOXFO  599 

no   wound   lo   hcconic   iiircctcd  willi   the  <lij)lit licriu  (for  ojjcration  of  intuba-. 
tion,  see  page  604). 

Tuberculous  Laryngitis. — This  usually  commences  at  the  interarv^tenoid 
plica  or  the  insertion  of  the  true  vocal  cords  at  the  base  of  the  arytenoid  carti- 
lai2;(\s.  'rul)crculous  ulcers  with  yellowish  base  are  present;  later  on,  other 
poi'tions  of  the  lar^-ngeal  nuicous  membrane  may  be  attacked.  Stenosis  is  rare 
from  this  cause  alone,  l)ut  the  occurrence  of  inflammatory  infiltration  of  the 
aryepiglottic  folds,  or  a  i)erichondritis,  ma>'  produce  obstruction.  If  the 
arytenoid  cartilages  are  involved  there  will  be  pain  on  deglutition. 

Syphilitic  Laryngitis. — This  occurs  as  a  gummatous  infiltration  and 
perichondritis,  with  or  without  ulceration.  In  sj^philitic  perichondritis  the 
cricoid  especially  is  attacked. 

Variolous  and  typhoid  laryngitis  is  a  metastatic  inflammation  which 
produces  uleeratiA-e  destruction  of  the  mucous  membrane.  In  the  first  named 
the  dangers  of  obstruction  are  due  in  the  beginning  to  inflammatory  swelling 
of  the  mucous  membrane  and  later  to  perichondritis.  In  tj^phoid  ulceration 
obstri.iction  rarely  occurs  until  later,  or  during  convalescence,  when  cicatri- 
cial contraction  may  follow  the  healing  of  the  ulcer;  or  the  obstruction  may 
be  due  to  perichondritis. 

Inflammatory  thickening  of  the  vocal  cords  (chorditis  vocalis  inferior 
hypertrophica),  due  to  chronic  catarrhal  inflammation  of  the  inferior  or  true 
vocal  cords,  may  produce  a  stenosis  sufficient  to  necessitate  tracheotomy. 

Tracheotomy. — The  term  laryngotomy  is  applied  when  an  opening  is  made 
from  without  into  the  larynx;  laryngotracheotomy  when  the  opening  is 
made  in  the  cricoid  cartilage  and  the  adjoining  tracheal  rings;  tracheotomy 
when  the  trachea  is  opened.  Generally  speaking,  however,  these  are  all  in- 
cluded under  the  latter  term.  The  operation  is  indicated  by  the  presence  of  a 
narrowing  of  the  normal  lumen  of  the  tube  sufficient  to  interfere  with  respiration 
and  endanger  life.  It  is  also  appHed  as  a  preliminary  operation  in  laryngo- 
tomy, laryngectomy,  and  other  operations  about  the  upper  air-passages  and 
pharyngeal  and  oral  cavities.  Among  the  acute  obstructions  requiring  the 
operation  as  an  emergency  procedure  may  be  mentioned  (1)  croup  and  diph- 
theria; (2)  inflammatory  affections  and  edema  of  the  larynx;  (3)  foreign  bodies 
in  the  larynx;  (4)  bilateral  abductor  paralysis;  (5)  spasm  of  the  larynx  (occa- 
sionally in  children,  rarely  in  adults).  It  is  also  employed  in  syphilitic  and 
tuberculous  disease  of  the  larynx  to  give  the  parts  rest;  in  tumors  of  the  larvnx 
and  for  the  removal  of  foreign  bodies  from,  the  trachea  and  bronchial  tubes. 

In  croup  and  diphtheria,  and  in  abductor  paralysis,  the  mistake  of  delaying 
the  operation  too  long  should  not  be  made.  To  be  of  benefit  it  should  be 
performed  while  there  is  yet  hope  of  sa^-ing  the  patient's  life,  and  not  post- 
poned until  euthanasia  constitutes  the  only  indication  in  the  case. 

The  anesthetic  employed  should  be  chloroform  whenever  practicable. 
This  is  usually  safe  in  the  case  of  children;  ether  is  very  irritating  to  the 
mucous  membrane  of  the  air-passages.  In  adults  cocain  (4  per  cent  solution) 
may  be  injected  under  the  skin  at  the  site  of  the  cutaneous  incision,  the  local 
anesthesia  thus  obtained  lasting  for  from  ten  to  tweh'e  minutes  (B  o  s  - 
wort  h) ,  and  being  efficient  for  all  the  structures  except  the  mucous 
membrane.  Finally,  in  the  case  of  very  young  children,  when  struggling  may 
be  prevented  by  wrapping  the  child  in  a  blanket,  and  of  older  children  who  are 


600 


SURGERY    OF   THE    NECK 


Fig.    355. — French's  Combined    Hemostatic 
Forceps  and  Retractor. 


practically  already  anesthetized  by  carbon  dioxid  poisoning,  anesthesia  may 
be  omitted  altogether. 

Choice  of  Operation. — Under  circumstances  of  extreme  emergency  the 
trachea  ma>'  be  opened  by  a  single  cut,  or  rapid  tracheotomy  (D  u  n  h  a  m), 
without  reference  to  the  presence  of  large  veins  or  the  thyroid  isthmus.  The 
trachea  and  larynx  are  steadied  laterally  by  the  thumb  and  finger  of  the  left 
hand,  or  a  large  tenaculum  hooked  deeply  and  firmly  into  the  cricoid  or  cri- 
cothyroid membrane.     Though  a  plexus  of  veins  lies  on  each  side  of  the  line 

of  incision,  A^et  not  infrecfuently  a  large 
vein  or  two,  increased  in  size  by  ob- 
structed breathing,  crosses  the  trachea. 
The  only  normal  artery  likely  to  be  met 
with  is  the  cricothyroid,  and  this  is 
placed  so  high  (at  the  lower  border  of 
the  thyroid  cartilage)  as  to  be  practi- 
cally out  of  the  way  in  almost  all  of  the 
operations  of  choice.  An  occasional 
arterial  abnormality,  the  arteria  thy- 
roidea  ima,  is  met  with;  it  rises  from 
the  arch  of  the  aorta  and  passes  directly 
upward  in  the  middle  line  to  the  lower 
border  of  the  thyroid.  In  a  low  or  infrathyroid  tracheotomy  the  innominate 
artery  may  be  endangered.  In  young  children  the  thymus  gland  may  be  an 
obstacle.  In  spite  of  these  latter  objections  and  of  the  fact  that  the  trachea 
in  children  is  more  deeply  placed  and  smaller  in  diphtheria  cases,  in  which  it 
is  desirable  to  place  the  tube  as  far  away  as  possible  from  the  pseudomem- 
branous exudation,  as  well  as  in  cases  of  malignant  disease  in  which  the  can- 
nula must  be  permanently  worn,  the  low  operation  should  be  performed. 
Where  the  isthmus  can  be  severed  between  two  ligatures,  the  tube  may  be 
placed  at  its  site.  In  an  emergency  reciuiring  rapid  tracheotomy,  and  under 
circumstances  which  de- 
mand prompt  interference 
on  account  of  threatened 
suffocation,  the  most  super- 
ficial portion  of  the  tube  is 
chosen  (laryngotracheo- 
tomy) . 

The  Operation.— The 
patient,  if  a  child,  is  wrap- 
ped in  a  blanket  which  is  snugly  pinned  so  as  to  confine  the  arms  at 
the  lateral  portions  of  the  body;  they  should  not  be  crossed  over  the 
chest.  He  is  placed  on  the  table  so  that  a  good  light  may  be  obtained. 
The  parts  to  be  operated  on  are  brought  into  prominence  by  a  hard  pillow 
made  by  wrapping  a  wine  bottle  in  a  towel,  or  some  similar  de\dce. 
The  instruments  required  are  a  scalpel,  half  a  dozen  artery  clamps 
(French's  clamps  are  the  most  convenient),  four  small  retractors  (Fig. 
356)  (two  sharp  and  two  blunt),  two  pairs  of  thumb  forceps,  a  grooved 
director,  a  strong  and  well  curved  tenaculum  for  fixing  the  trachea  (Fig.  357), 
curved  and  straight  blunt  pointed  scissors,  an  aneurism  needle,  and  curved  and 


Fig.  356. — Pilcher's  Retractors. 


TI 


IK    LAKVXX,    TUACHKA,    AXD    HYOII)    BOXE 


601 


Fig 


357. — Combined 
Grooved  Director 

AND     TeXACULUM. 


?trai^-ht  needle:?.  iSilk  ami  eutgut  arc  also  needed  lor  .sutureand  ligature  purposes. 

An  assortment  of  tubes  must  be  at  hand.     The  one  best  adapted  to  the  case  is 

prepared,  with  tapes  attached,  and  placed  con^■enientl>'  near.     The  other  in- 
struments are  i^laced  in  the  order  in  which  the}-  are  to  be  used.     A  median 

incision  is  made  from  the  lower  edge  of  the  cricoid  cartilage 

downward  for  from  an  inch  and  a  half  to  two  inches,  in- 
cluding the  skin  and  superficial  fascia;  the  anterior  jugular 

veins,  one  on  each  side  of  the  larynx  and  trachea,  pass 

downward  and  are  joined  by  a  transverse  tmnk  just  above 

the  sternum.     The  lateral  ribbon-shaped  muscles  (the  crico- 
thyroid above  and  the  sternoth}Toid  below)  are  separated 

by  the  handle  of  the  scalpel  and  drawn  apart  by  small 

blunt  retractors,  so  that  the  deep  fascia  is  brought  into 

view.     The  latter  divides  into  two  layers  to  inclose  the 

isthmus  of  the  thyroid,  which  is  recognized  b}-  its  pinkish 

red  appearance,  resting  on  the  second  and  third  rings  of 

the  trachea.     The  deep  fascia  is  carefully  nicked  just  below 

the  lower  border  of  the  isthmus  and  divided  on  a  grooved 

director,  the  incision  baring  the  rings  of  the  trachea  with 

some  loose  connective  tissue  in  front.     A  stout  tenaculum 

is  now  inserted,  point  upward,  at  the  lower  border  of  the 

isthmus  into  the  trachea  to  steady  the  latter  while  it  is 

being  incised.     Whenever  possible,  a  loop  of  strong  silk  is 

passed  through  each  edge    of  the   tracheal   incision   for 

purposes  of  retraction.     As  large  a  tube  as  can  be  passed  without  crowding 

should  be  used. 

Various  tracheotomy  tubes  have  been  devised;  the  best  is  that  known 

as  the  Cohen  model  (Fig.  358).     It  is  flattened  from  side  to  side,  so  that 

its  introduction  is  facilitated  and  the  tendency 
of  the  posterior  wall  to  bulge  forward,  as  a 
consequence  of  wide  separation  of  the  edges 
of  the  di^•ided  tenaculum  rings,  is  lessened. 
A  pilot  trocar  aids  in  the  introduction  in 
emergency  cases  and  during  the  after-treat- 
ment, but  if  the  loops  of  thread  above  men- 
tioned can  be  placed  in  position  and  retained, 
this,  as  well  as  tracheal  dilators,  can  be  dis- 
pensed with.  The  wound  is  closed  by  inter- 
rupted sutures,  except  at  the  point  where  the 
tube  emerges,  and  dressed  with  iodoform 
gauze. 

The  tube  is  secured  in  place  by  tapes  about 
the  neck  and  covered  by  a  number  of  tliick- 
nesses  of  gauze  saturated  with  a  steriHzed 
normal  salt  solution.  The  atmosphere  of  the 
room  is  kept  moist  and  at  a  temperature  of  at  least  80°  F.  In  croup  and 
cUphtheria  cases  a  watchful  care  is  to  be  exercised  to  prevent  the  tube  from 
becoming  blocked  by  pieces  of  false  membrane.  The  inner  tube  is  to  be  re- 
moved and  cleansed  from  time  to  time.     In  an  emergencv  both  tubes  are  to 


Fig.      358.  —  Cohen's     Tracheotomy 
Tubes. 

1,  Outside  tube  and  obturator;  2, 
obturator;  3,  inside  tube;  a,  cross-sec- 
tion of  the  tube. 


602 


SURGERY    OF   THE    NECK 


be  removed  at  once  and  the  patency  of  the  opening  maintained  by  the  loops 
of  thread.  The  tul^e  should  be  dispensed  with  at  the  very  earliest  possible 
moment. 

In  suprathyroid  tracheotomy  the  incision  commences  opposite  the  middle 
of  the  thyroid  cartilage.  The  isthmus  is  loosened 
by  the  handle  of  the  scalpel  and  crowded  down- 
ward, where  it  is  held  by  a  small  Ijlunt  retractor 
while  the  trachea  is  steadied  l)y  a  tenaculum  and 
the  first  two  or  three  rings  incised.  In  laryngo- 
tracheotomy  the  incision  is  carried  upward  in- 
stead of  downward,  dividing  the  cricoid  cartilage 
and  the  cricothyroid  membrane.  This  operation  is 
rarely  required  except  for  exploratory  purposes, 
and  in  case  the  isthmus  is  placed  abnormally  high 
and  is  very  broad.  Cricothyroid  laryngotomy  is 
an  exceedingly  simple  operation  and  hence  is  some- 
times employed  w^hen  the  emergency  of  the  case  de- 
mands a  speedy  opening  of  the  windpipe.  The  in- 
cision is  confined  to  the  cricothyroid  membrane. 
A  tube  introduced  at  this  point  is  not  well  toler- 
ated and  but  a  limited  space  is  afforded  for  its  in- 
troduction, so  that  only  a  small  tube  can  be  used. 
The  After  Course  and  Treatment  in  Tracheo- 
tomy Cases. — When  the  operation  is  performed  for 
the  relief  of  stenosis  due  to  diphtheritic  conditions 
of  the  larynx  or  trachea,  in  addition  to  meeting  the 
immediate  indications  for  the  prevention  of  suffoca- 
tion and  removing  whatever  diphtheritic  membrane 
may  be  detached  or  detachable,  the  procedure  permits  the  application  of 
proper  local  remedies  to  the  diseased  area.  The  tracheal  wound  also  gives  ready 
exit  to  loosened  portions  of  pseudomembrane,  which  are  propelled  upward  by 
-acts  of  coughing.  This  loosening  is  hastened  by  inhalations  of  steam.  The 
stream  of  steam  from  a  croup 
kettle  (Fig.  359)  or  from  a  com- 
mon teakettle  with  a  tube  ex- 
tension on  the  spout,  is  directed 
so  as  to  be  inhaled  through  the 
cannula.  The  addition  of  gly- 
cerin to  the  boiling  water  is  said 
to  hasten  the  separation  of  the 
diphtheritic  deposit  by  pro- 
ducing a  serous  transudation 
of  the  mucous  membrane  (P. 

Voigt).     The  entire  effort  must  be  directed  toward  preventing  the  drying 
of  the  secretions  of  the  larynx  and  trachea. 

By  the  flapping  noise  the  practised  ear  will  at  once  detect  when  a  portion 
of  diphtheritic  membrane  is  loosened  but  cannot  escape.  Under  these  cir- 
cumstances the  curved  intracannular  forceps  (Fig.  360),  which  should  always  be 
at  hand,  are  to  be  used.     They  are  passed  through  the  cannula,  the  jaws  opened, 


Fig.  359. — Ckoup  Kettle. 


Fig.  360. — Ixtracaxxular  Alligator  Forceps. 


THE    LARYNX,    TRACHKA,    AM)    IIVOII)    ]U)NE  603 

and  while  a  eou^hiii;;"  el't'ort  is  made  the  jaws  are  closed  and  llie  instrunient  with- 
drawn. This  may  be  frequently  repeated,  but  if  it  is  found  that  the  loose  piece 
is  not  caught  after  several  trials,  the  entire  cannula  should  be  removed, 
when  the  mass  A\ill  almost  immediately  follow.  If  not,  the  forceps  should  be 
carried  through  the  wound  to  the  interior  and  further  efforts  made. 

I'he  inner  tube  may  be  removed  occasionally  for  purposes  of  cleansing. 
During  the  intervals  a  compress  made  of  a  num])cr  of  thicknesses  of  gauze, 
and  moistened  with  a  sterilizcMl  salt  solution,  should  ])e  kept  over  the  cannula. 

The  Treatment  of  the  Wound. — Complete  aseptic  regime  cannot  be 
maintained  in  the  treatment  of  the  wound.  A  piece  of  iodoform  gauze  may 
be  placed  between  the  shield  of  the  cannula  and  the  wound  surfaces,  and 
changed  frequently.  In  nondiphtheritic  cases  the  wound  usually  heals  with- 
out complication.  Infection  of  the  wound  is  very  likely  to  follow  in  cases 
of  diphtheritic  inflanunation  of  the  trachea.  The  infected  wound  surface  is 
to  be  treated  with  gauze  compresses  wrung  out  of  a  5  per  cent  carbolic  acid  solu- 
tion or  disinfected  with  a  5  or  10  per  cent  chlorid  of  zinc  solution.  Phlegmonous 
inflammation  of  the  connective  tissue  of  the  neck  may  occur.  This  is  an  ex- 
ceedingly serious  complication  and  is  to  be  met  by  the  frequent  application 
of  compresses  dipped  in  sokitions  of  corrosive  sublimate,  1  :  2000  in  50  per 
cent  alcohol,  or  the  carbolic  acid  and  opium  lotion  (see  page  160). 

Diphtheritic  ulceration  of  the  anterior  tracheal  wall  may  arise  in  con- 
sequence of  severe  diphtheria  of  the  mucous  membrane  and  of  the  wound.  A 
tracheal  stenosis  may  arise  from  this  cause,  necessitating  in  very  rare  instances 
a  second  tracheotomy.  Or,  the  tracheal  wound  may  fail  to  close  and  a  subse- 
quent plastic  procedure  become  necessary. 

Diphtheritic  Paralysis. — Motor  paralysis  of  the  muscles  of  the  palate  and 
sensory  paralysis  of  the  nerve-fibers  at  the  entrance  of  the  larynx  permit  fluids 
to  pass  through  the  glottic  opening  and  out  of  the  tracheal  wound.  The  diet 
therefore  should  be  restricted  to  sterilized  milk.  Should  the  patient's  nutrition 
suffer  because  of  inability  to  swallow  sufficient  milk,  the  stomach,  tube  should 
be  emjDloyed  or  nutrient  enemas  administered. 

Paralysis  of  the  vocal  cords  sometimes  remains  after  severe  laryngeal 
diphtheria,  with  resulting  aphonia.  Spontaneous  recovery  usually  takes  place, 
as  in  other  paralyses  of  diphtheritic  origin.  Electric  applications  to  the  mus- 
cular apparatus  of  the  larynx  are  useful  in  obstinate  cases. 

Ulceration  of  the  trachea  from  improperly  curved  tubes  occurs  in  a  certain 
l^roportion  of  cases.  The  resulting  hemorrhage  is  sometimes  sufficient  to  cause 
obstructed  breathing.  The  introduction  of  a  tampon  cannula  (Trendelen- 
burg's, page  535)  will  arrest  the  bleeding.  The  preventive  treatment  con- 
sists in  removal  of  the  cannula  as  early  as  possible. 

Granulomas  sometimes  form  at  the  edges  of  the  tracheal  wound  and  in  the 
tube  track.  When  within  the  trachea,  they  mark  the  site  of  pressure  ulcers. 
When  in  the  latter  location,  they  may  cause  suffocative  attacks  after  the 
removal  of  the  tube  and  the  closure  of  the  external  wound,  by  being  drawn  in 
with  the  inspired  air.  The  granulomas  may  be  destro^'ed  by  nitrate  of  silver 
or  chromic  acid,  the  cannula  being  replaced  until  smooth  cicatrization  of  the 
sm-faces  has  been  secured. 

Attacks  of  suffocation  are  sometimes  observed  after  removal  of  the  tul)e, 
when  no  discoverable  cause  for  these  is  present.     They  are  due   to  psycliic 


604  SURGERY   OF   THE   NECK 

causes  and  paralysis  from  long  inactivity  of  the  posterior  cricoarytenoid 
muscles.  The  patient  should  be  encouraged  to  make  long  and  forcible 
inspiratory  efforts.     Electric  treatment  is  also  useful. 

Permanent  Removal  of  the  Tube. — In  diphtheria  cases  the  cannula  can 
generally  be  dispensed  with  after  the  fifth  day.  If,  upon  dispensing  with  the 
tube  for  a  short  time,  the  oljstructed  breathing  recurs,  the  tube  should  be 
replaced  and  another  trial  made  on  the  following  day.  A  compress  placed 
over  the  wound  for  a  few  seconds  while  the  patient  is  directed  to  make 
forced  inspiratory  and  expiratory  efforts  will  assist  in  restoring  the  func- 
tion of  the  muscular  apparatus  of  the  glottis,  when  the  difficulty  is  due 
to  inactivity  of  this.  When  tracheotomy  is  performed  for  foreign  bodies, 
it  may  not  be  necessary  to  employ  a  cannula;  at  the  most  this  will  be 
required  only  for  a  day  or  two  after  the  removal  of  the  foreign  body. 
In  stenosis  from  tumors  or  cicatricial  bands,  unless  the  cause  can  be 
removed  by  other  operative  procedures,  the  tube  must  be  worn  for  life. 
Under  these  circumstances  the  track  of  the  tube  becomes  covered  with  mucous 
membrane  from  within  outward,  and  by  a  layer  of  epidermis  from  without 
inward,  the  two  layers  meeting.  After  preliminary  tracheotomy  the  cannula 
can  be  removed  as  soon  as  the  operation  is  over,  as  a  rule,  or  it  may  be  left  in 
place  for  a  short  time  to  prevent  blood  and  wound  secretions  from  entering  the 
air-passages. 

In  acute  cases  the  wound  heals  rapidly  after  removal  of  the  tube.  In  those 
who  have  worn  a  tube  for  a  long  time  a  minute  fistulous  opening  may  remain 
after  its  removal. 

Persons  who  are  compelled  to  wear  a  tracheal  cannula  permanently  should 
])e  taught  how  to  remove  and  cleanse  the  tube.  It  is  better  for  these  patients 
to  wear  a  hard  vulcanized  rubber  tube  of  solid  construction  to  avoid  accidents 
arising  from  corrosion  of  the  metal  tube  at  the  point  where  it  is  soldered  to  the 
shield. 

Intubation  of  the  Larynx  (O'Dwyer). — This  operation  has  largely 
replaced  tracheotomy  in  cases  of  diphtheria.  It  is  also  employed  in  stenosis  of 
the  larv^nx  from  causes  other  than  malignant  disease.  As  in  the  case  of  trach- 
eotomy, it  should  be  performed  early  in  order  that  the  greatest  benefit  may  be 
derived  from  its  use.  It  has  the  disadvantage  of  rec|uiring  special  instruments 
for  its  performance,  whereas  in  tracheotomy  the  urgently  demanded  relief  can 
be  obtained  by  means  of  instruments  usually  at  hand.  This  disadvantage  is 
offset,  however,  by  the  fact  that  it  entails  neither  loss  of  blood  nor  shock,  and 
can  be  speedily  performed. 

The  instruments  as  ordinarily  supplied  are  (1)  a  set  of  tubes  with 
obturators,  adapted  to  the  ages  between  one  and  twelve  years;  (2)  a  metal  gage 
to  aid  in  the  selection  of  the  proper  tube;  (3)  a  mouth-gag;  (4)  a  tube  intro- 
ducer; (5)  a  tube  extractor  (Fig.  361). 

Operation. — The  child  is  held  upright  on  the  lap  of  an  attendant,  with  its 
head  resting  on  the  latter's  left  shoulder,  so  that  the  body,  head,  and  neck  are 
in  a  straight  line.  The  arms  are  held  securely  against  the  patient's  body.  The 
mouth-gag  is  inserted  in  the  left  angle  of  the  mouth  as  far  back  as  possible 
between  the  teeth,  and  the  latter  forced  apart  as  far  as  possible.  The  proper 
sized  tube  is  attached  to  the  introducer  by  its  obturator,  a  piece  of  thread 
attached  to  the  tube  by  passing  it  through  a  hole  provided  for  the  purpose,  and 


THE    LARYNX,    TKACllKA,    AXU    HYUIU    BONE 


605 


the  thread  wound  around  the  Httle  finder  of  the  risi^ht  hand  of  the  operator. 
This  thread  is  to  facihtate  the  immediate  withdrawal  of  the  tul)e  shoukl  it 
become  improi)erly  lodged.  The  introducer  is  grasped  in  the  right  hand  whik^ 
the  tip  of  the  left  index-finger  is  passed  to  the  epiglottis,  identifying  it.  The 
latter  is  raised  so  as  to  uncover  the  glottic  opening,  and  the  tube  is  passed, 
guarded  liy  the  index-finger.  As  the  tul)e  glides  over  the  now  vertically  placed 
ejiiglottis  and  enters  the  glottis,  the  guiding  index-finger  is  shifted  posteriorly 
toward  the  pharyngeal  wall,  where  it  prevents  the  tube  from  slipping  into  the 
esophagus.  The  proper  position  of  the  tube  being  assured,  it  is  at  once  driven 
home  and  at  the  same  time  released  from  its  obturator  and  the  introducer  by 


|H 

^Hl 

^^^^^^^^^^^^^^B 

^1 

■^B 

^^1 

^^K^y 

1/  j^^^^^^^^^^^B 

B 

W^ 

t/m 

^R 

«'i  v^^^^^^^^^^^i 

I 

^p^l^ 

■  ^ 

m 

"B| 

. 

L 

9^ 

4 

'  '         .""  '  v*^ 

.   ^M 

^»##iiiiii )    i 

J 

W!^ 

Fig.  361. — O'Dwyer's  Intubation  Instruments. 
A,   Tube  with  obturator;   B,  tube;   C,  obturator;   D,  metal  gage;   E,  mouth-gag;   F,  introducer;   G,  ex- 
tractor; H,  silk  cord. 


pushing  forward  the  slide  on  the  latter  with  the  thuml)  of  the  right  hand.  The 
introducer  with  the  attached  obturator  is  now  withdrawn.  The  left  index- 
finger  then  identifies  the  tube  in  position,  and,  if  not  placed  well  down  in  the 
glottic  opening,  it  is  pressed  home  by  the  same  finger.  The  gag  is  then  re- 
moved. If  the  breathing  is  relieved,  the  gag  is  again  introduced  and  the  tube 
steadied  with  the  finger  as  before,  while  the  thread  is  withdrawn.  In  case  the 
tube  is  expelled  by  the  subsequent  coughing  efforts,  a  larger  one  should  be 
introduced. 

The  removal  of  the  tube,  which  is  usually  safe  after  from  three  to  nine 
days,  is  effected  l^y  a  maneuver  similar  to  that  by  which  it  was  introduced.  The 
child  is  held  in  the  same  manner,  the  gag  introduced,  the  top  of  the  tube  identi- 
fied bv  the  left  index-finger,  and  the  extractor  introduced.     The  blades  of  the 


606  SURGERY    OF    THE    NECK 

latter  are  released  by  a  device  on  the  shank  worked  by  the  thumb  of  the  hand 
which  grasps  the  instrument  as  the  point  of  the  latter  passes  into  the  lumen  of 
the  tube.  The  spread-out  blades  of  the  extractor  engage  the  tube  and  the 
latter  is  withdrawn. 

The  following  precautions  must  l)e  observed:  (1)  The  operator  should  be- 
come thoroughly  familiar  with  the  mechanism  of  the  instruments,  and,  if  possi- 
ble, practise  the  operation  upon  the  cadaver;  (2)  the  finger  should  not  be  held 
too  long  over  the  glottis  lest  suffocation  take  place. 

The  dangers  of  the  operation  are  the  following:  (1)  Membrane  may  be 
pushed  ahead  of  the  tube  and  produce  obstruction.  This  will  necessitate  with- 
drawing the  tube  immediately  and  waiting  until  the  loosened  membrane  has 
been  expelled  before  reintroducing  it.  (2)  Failure  to  remove  the  thread  may 
lead  to  the  swallowing  of  the  latter,  followed  b}^  the  tube  itself.  Should  this 
occur,  another  tube  must  be  introduced  at  once.  The  swallowed  tube  will  be 
expelled  with  the  bowel  movements. 

Tumors  of  the  Larynx  and  Trachea. — Papilloma. — This  is  a  connective- 
tissue  new  formation  (fibrosarcoma)  with  a  broad  base  and  fissured  surface. 
The  smaller  growths  occur  isolated  or  in  groups  at  the  free  edge  of  the  anterior 
commissure  of  the  vocal  cords.  Large  growths  occupy  by  preference  the 
aryepiglottic  ligaments  and  occasionally  the  posterior  surface  of  the  epiglottis. 
These  occur  generally  in  children.  Pediculated  fibromas  originate  from  the 
free  edge  or  lower  surface  of  the  vocal  cords.  The  first  named  usually  give 
rise  to  progressive  aphonia  at  the  commencement;  later  on  they  may 
increase  in  size  sufficiently  to  cause  dyspnea.  The  pediculated  fibromas 
may  give  rise  to  suffocation  early  in  their  history. 

Sarcoma  of  the  larynx  is  rare,  and  when  it  does  occur  it  springs  from  the 
lateral  wall.  Myxoma,  angioma,  and  adenoma  of  the  lary'nx  are  verj^  rare. 
Enchondroma  of  the  thyroid  and  cricoid  cartilages  is  also  very  rare.  Large 
intralaryngeal  growths  of  benign  origin  are  l^est  dealt  with  by  laryngotomy. 

Tumors  of  the  trachea  are  exceedingly  rare,  except  the  granuloma  due  to 
the  use  of  a  tracheal  cannula.  Sarcoma  and  submucous  fibrosarcoma  have 
been  observed. 

Cancer  of  the  Larynx.— This  is  the  most  important  of  the  mahgnant 
growths.  It  occurs  both  as  a  primary  affection  and  as  an  extension  of  disease 
from  carcinoma  of  the  tongue,  fauces,  and  esophagus.  It  is  essentially  a  disease 
of  adult  life.  It  may  arise  in  the  mucous  membrane  of  the  ventricles,  vocal 
cords,  or  ventricular  bands  (intrinsic  cancer) ;  in  the  aryepiglottic  folds,  or  the 
covering  of  the  arytenoids,  or  the  interarytenoid  fold  (extrinsic  cancer).  The 
first  named  is  papillomatous  in  character,  almost  alwavs  occurring  as  a  warty 
growth.  Lymphatic  glandular  infection  and  dissemination  are  uncommon. 
On  the  other  hand,  in  the  extrinsic  variety  the  disease  extends  rapidly  and 
infects  the  lymph-glands  promptly.  The  clinical  importance  of  the  distinction 
is  further  emphasized  by  the  fact  that  implication  of  the  surrounding  parts 
occurs  far  more  freciuently  in  the  extrinsic  than  in  the  intrinsic  variety,  and 
operative  interference  (excision  of  the  corresponding  half  of  the  larynx,  or 
thyrotomy  and  thorough  removal  of  the  soft  tissues)  gives  far  better  results 
in  the  intrinsic  form  of  the  disease  than  in  the  extrinsic.  Indeed,  in  the 
majority  of  cases  of  the  latter,  as  well  as  in  those  cases  of  the  former  too  far 
advanced  for  thyrotom}-,  the  only  hope  of  saving  the  patient  from  death  from 


TlIK    LARYXX,    TI{A( 'II  lOA,    AXD    11  VOID    BONE  607 

suffocation  ivsulcs  in  Iruflicoloiny.  'I'hc  slight  tendency  to  involvement  of 
the  thyroid  cartilage^  in  the  intrinsic  form  of  the  disease,  and  the  low 
mortality  following  thyrotomy  as  comi:)ared  with  that  following  complete  or 
even  partial  laryngotomy,  have  gi^•(Ml  a  h()i)eful  impetus  to  the  effort  to 
diagnose  the  disease  early  by  the  i-emoval  with  the  intralaryngeal  forceps 
and  the  microscopic  examination  of  portions  of  all  suspicious  growths  in  the 
larynx  occurring  in  middle-aged  adults. 

The  laryngoscoiw  is  to  be  employed  in  the  diagnosis  of  tumors  of  the 
larynx.  The  small  benign  growths  are  best  removed  l)y  intralaryngeal 
operations  at  the  hands  of  skilled  laryngologists.  In  malignant  disease,  the 
tliagnosis  being  established  early  by  microscopic  examination  of  portions  re- 
moved by  the  laryngologist,  either  thyrotomy  or  partial  extirpation  of  the 
larynx  is  indicated  {vide  supra).  If  the  growth  has  extended  to  the  pharynx 
or  wppvv  poi-tion  of  the  esophagus,  operation  is  not  admissible. 

Laryngeal  Stenosis  of  Cicatricial  Origin. — Ulcerative  processes,  of 
which  that  arising  from  syphilitic  laryngitis  is  the  most  common,  are  the 
most  frequent  causes  of  this  condition.  Next  in  frequency  is  typhoid  ulcer- 
ation. The  causes  which  produce  primary  inflammatory  stenosis  rarely 
produce  cicatricial  stenosis. 

Traumatism  may  cause  stenosis  of  the  larynx,  such,  for  instance,  as  follows 
ulcerative  or  suppurative  conditions  due  to  the  pressure  of  angular  foreign 
bodies,  or  wounds  from  pointed  foreign  bodies.  Gaping  transverse  incised 
wounds  which  heal  by  the  formation  of  dense  cicatricial  tissue,  and  fractures 
of  the  larynx  in  which  the  fragments  remain  unreduced,  will  also  give  rise  to 
stenosis. 

The  diagnosis  of  stenosis  is  based  on  the  history  of  the  case,  the  peculiar 
whistling  noise  accompanying  the  respiratory  movements,  and  the  dyspnea. 
Laryngoscopic  examination  will  reveal  the  location  and  degree  of  the  affection. 

The  treatment -consists  in  attempts  at  dilatation  through  the  glottic  open- 
ing, or  a  tracheotomy  wound  if  this  operation  is  demanded,  preliminary  incision 
of  the  cicatricial  tissue  being  practised  when  necessary.  The  dilatation  is 
best  carried  on  by  the  use  of  intubation  tubes,  progressively  increasing  sizes 
of  these  being  introduced  and  worn.  Recurrence  is  the  rule,  however,  both 
in  dilatation  and  in  resection  of  the  larynx,  cicatricial  tissue  taking  the  place 
of  that  removed  in  the  latter.  In  cases  otherwise  irremediable  an  intubation 
tube  if  possible,  or,  this  being  impracticable,  a  tracheal  cannula  must  be  per- 
manently worn.  To  improve  the  speech  a  separate  tube  which  passes  upward 
toward  the  glottis  and  is  attached  to  the  tracheal  cannula  is  to  be  employed 
(Richet).  The  instrument  resembles  the  artificial  larynx  of  Gussen- 
b  a  u  e  r  .  This  device  is  also  to  be  employed  in  cases  in  which  collapse 
.of  the  laryngeal  framework  follows  removal  of  diseased  cartilages. 

Laryngotomy. — In  former  times  laryngotomy  was  frequently  resorted 
to  for  the  removal  of  foreign  bodies  lodged  above  the  true  vocal  cords,  in 
cases  where  the  symptoms  were  not  sufficiently  urgent  to  demand  tracheot- 
omy. The  perfection  of  intralaryngeal  methods  and  the  introduction 
of  cocain  anesthesia  have  restricted  the  indications  for  this  operation  to 
cases  in  which  intralaryngeal  methods  of  extraction  have  failed,  and  to 
cases  of  fracture  of  the  larynx  in  which  fragments  of  cartilage  project  into  the 
lumen.     The  complete  separation  of  the  two  halves  of  the  larynx  after  total 


608  SURGERY   OF   THE   NECK 

lan-ngotomy,  or  laryngofissure,  as  it  is  sometimes  called,  leads  to  changes 
in  the  voice,  the  two  ])ortions  failing  to  resume  their  exact  original  relative 
positions. 

Thyrotomy  has  replaced,  to  a  great  extent,  laryngotomy.  It  is  indi- 
cated in  cases  of  impacted  foreign  bodies  in  the  glottis  and  benign  tumors 
not  amenable  to  intralarvngeal  methods  of  removal.  Preliminary  tracheotomy 
and  the  introduction  of  a  tampon  cannula  are  necessa^3^  If  possible,  this 
should  be  done  three  or  four  weeks  beforehand. 

Operation. — An  incision  is  made  from  the  pomum  Adami  to  the  crico- 
thyroid memljrane.  The  point  of  the  knife  enters  the  cavity  of  the  larynx 
through  the  membrane  and  separates  the  latter  from  the  thyroid  cartilage  by 
a  transverse  cut  in  both  directions.  This  avoids  injury  to  the  cricoid  artery. 
The  sternothyroid  muscles  are  separated;  the  cricothyroid  of  each  side  is  to  be 
preserved  as  far  as  possible.  One  blade  of  heavy  blunt  scissors  is  introduced 
into  the  cavity  of  the  larynx  between  the  vocal  cords,  and  the  thyroid  cartilage 
split  along  the  median  line  from  below  upward  and  from  within  outward. 
Where  the  cartilage  is  ossified,  bone  cutting  forceps  must  be  used.  If  the 
cartilage  is  sufficiently  flexible,  in  order  to  secure  accurate  reposition  and  avoid 
changes  in  the  voice  it  is  advantageous  to  preserve  the  uppermost  edge  intact 
(C  o  a  t  e  s).  The  cricoid  preserves  the  relation  of  the  two  halves  sufficiently 
well,  as  a  nile,  however.  After  complete  separation,  if  more  room  is  necessary, 
the  thyrohyoid  ligament  is  to  be  divided  transversely,  after  which  the  th^^roid 
cartilage  may  be  widely  separated  by  means  of  retractors.  A  small  opening 
will  be  sufficient  for  the  removal  of  a  foreign  body,  but  more  space  will  be 
rec|uired  for  the  extirpation  of  a  tumor. 

In  replacing  the  parts  care  must  be  exercised  lest  the  vocal  cord  of  one  side 
is  placed  on  a  lower  level  than  the  other.  The  cartilage,  as  well  as  the  overhang 
parts,  must  be  accurately  sutured;  a  tracheal  cannula  is  to  be  left  in  place 
for  a  few  days  to  prevent  emphysema  of  the  neck  from  air  forced  between  the 
sutures  into  the  connective  tissue. 

Extirpation  of  the  Larynx  (Laryngectomy).— This  operation  is  some- 
times performed  for  malignant  disease  of  the  larynx.  The  operation  is  to  be 
preceded  by  low  tracheotomy,  performed,  if  possible,  two  or  three  weeks 
beforehand,  and  the  introduction  of  the  tampon  cannula  at  the  time  of  the 
operation. 

Operation. — An  incision  is  made  from  the  hyoid  bone  to  the  edge  of  the 
cricoid.  From  each  extremity  of  this  incision  a  transverse  cut  is  made  in  the 
direction  of  the  anterior  edge  of  each  sternomastoid  muscle.  The  two  quad- 
rangular flaps  of  skin  are  turned  back  and  the  separation  of  the  larynx  effected 
from  below  upward  (Billroth)  as  follows :  The  trachea  is  separated 
from  the  cricoid  cartilage  by  a  transverse  cut,  and  the  larynx  drawn  forcibly 
ujjward  and  fon\-ard  by  a  strong  tenaculum.  This  gives  access  to  the  posterior 
wall  of  the  larsmx,  from  ^^-hich  the  esophagus  is  to  be  separated.  The  separa- 
tion is  continued  posteriorly  and  laterally  from  below  upward,  the  growth, 
which  usually  occupies  the  region  of  the  arytenoid  cartilages,  separating  with 
the  larynx.  If  it  invades  the  pharyngeal  wall,  this  is  to  be  removed  as  far  as 
necessary'.  In  separating  the  larynx  from  the  thyroid  body  the  knife  must 
be  kept  close  to  the  former,  in  order  to  avoid  injury  to  the  superior  thyroid 
artery  as  it  passes  from  above  to  the  inner  edge  of  the  lobe.     Finally,  the 


THE    LAUYXX,    TRACliKA,    A.\l)    HYOID    BONE 


609 


larynx  is  separatcel  from  its  attachments  to  the  tongue.  In  small  growths 
the  separation  may  be  made  at  the  th3Tohyoid  memljrane,  the  epiglottis  re- 
maining intact.  In  more  extensive  growths  the  epiglottis  also  must  be  re- 
moved, in  which  case  the  final  separation  takes  place  at  the  deep  muscles  of 
the  tongue.  It  may  also  be  necessary,  if  .such  a  radical  procedure  is  indicated, 
to  remove  portions  of  the  underlying  muscles  (sternohyoid,  sternothyroid,  and 
thyrohyoid).  Here  both  the  superior  and  the  inferior  thyroid  artery  must 
be  divided  and  ligated.  'rhe  hemorrhage  may  l)c  troublesome  if  it  becomes 
necessary  to  remove  portions  of  the  thyroid  gland;  the  ascending  palatine 
artery  ma}"  be  injured  in  the  removal  of  portions  of  the  pharyngeal  wall. 

Partial  lateral  excision  of  the  larynx,  one  half  being  preserved 
(I^  i  1 1  r  o  t  h  ,  Max  S  c  h  e  d  e  ,  H  a  li  n),  has  been  perfoi'med  when  the 
disease  has  been  ap]5arently  limited  to  one  side.  The  th}-roid  cartilage  is 
separated  in  the  median  line,  as  in  thyrotomy,  and  one  lateral  half  of  the 
larynx  removed  from  below  upward. 
The  epiglottis  can  usualh'  be  pre- 
served. 

Partial  Laryngectomy 
(Cohen). — The  posterior  third  of 
the  thyroid  cartilage  has  been  found 
remarkably  free  from  disease  in  epi- 
thelial carcinoma.  Inasmuch  as  this 
portion  of  the  cartilaginous  frame- 
work of  the  glottis  serves  for  the  at- 
tachment of  certain  muscles  which 
are  of  importance  in  the  act  of  swal- 
lowing (inferior  constrictor,  stylo- 
pharyngeus,  and  palatopharyngeus) 
the  importance  of  the  preservation 
of  this  is  manifest.  The  steps  of  the 
operation  are  carried  out  as  in  total 
extirpation,  except  that  the  thyroid 
cartilage  is  split  each  side  of  the 
median  line  and  along  the  line  of  at- 
tachment of  the  inferior  constrictor  muscle  to  the  cartilage.  The  entire  larynx 
with  the  exception  of  this  portion  of  thyroid  cartilage,  including  the  interior  of 
the  glottis  itself,  comes  awa}'  in  one  piece.  In  the  first  case  of  epithelial  carcin- 
oma of  the  larj^nx  operated  on  after  the  method  proposed  by  Prof.  Cohen, 
in  my  service  at  the  ]\Iethodist  Episcopal  Hospital,  the  patient  lived  twenty- 
seven  months,  finally  dying  of  the  recurrence  of  the  disease  in  the  cicatricial 
tissue  and  skin  surface. 

After-treatment. — The  parts  about  an  ordinary  tracheotomy  tube,  if 
this  is  used  in  the  after-treatment,  are  to  be  packed  carefully  with  iodoform 
gauze.  Or  the  tampon  cannula  may  be  worn.  The  trachea  is  to  be  protected 
against  the  entrance  of  wound  secretions,  in  order  to  avoid  septic  bronchitis 
and  pneumonia.  Feeding  is  carried  on  in  the  beginning  b}'  means  of  the 
stomach  tube.  The  wound  is  partially  sutured  above  and  the  cavity  from 
which  the  larynx  has  been  removed  packed  with  oxid  of  zinc  or  plain  sterile 
gauze.  Dailv  repacking  and  antiseptic  irrigation  are  necessary'.  The  wound 
40 


Fig.  362.- 


P ark's  Modification  of  Gussenbauer's 
Artificial  Larynx. 


610  SURGERY   OF   THE   NECK 

gradually  retracts  to  a  narrow  opening  above  the  tracheotomy  tube.  The 
latter  is  to  be  eventually  transferred  to  this  and  the  low  tracheotomy  wound 
permitted  to  heal.  Before  final  contraction  of  the  parts  above  the  stump  of 
the  trachea  occurs  an  artificial  larynx  is  to  be  fitted  (G  u  s  s  e  n  b  a  u  e  r ,  Fig. 
362).  The  speech  thus  obtained  is  such  as  can  be  easily  understood,  though  it 
is  absolutely  monotone.  The  vocahzing  portion  of  the  apparatus  obstructs  the 
breathing  as  soon  as  mucus  collects  upon  it,  and  patients  must  be  taught  to 
remove  it  for  purposes  of  cleansing.  Without  it,  conversation  can  be  carried  on 
in  a  whisper,  the  consonant  sounds  being  formed  by  the  closing  of  the  exter- 
nal opening  and  tlie  forcing  of  the  air  through  the  pharyngeal,  oral,  and 
nasal  cavities. 

When  eating,  the  patient  replaces  the  vocalizing  apparatus  by  an  obturator 
which  closes  the  upper  or  chimney  portion  of  the  artificial  larynx  (P .  B  r  u  n  s) 
and  prevents  food  from  being  forced  into  the  tube.  He  soon  learns  to  substitute 
the  base  of  the  tongue  for  the  removed  epiglottis  and  dispenses  with  the  obtura- 
tor entirely. 

When  one  lateral  half  of  the  larj^nx  is  removed,  the  use  of  an  artificial  lar}-nx 
may  not  be  necessar}^  (]\I  a  x   S  c  h  e  d  e) . 

Mortality. — The  immediate  mortality  following  total  laryngectomy  is  about 
40  per  cent.  Of  those  who  recover  from  the  operation  itself,  about  50  per  cent 
die  of  septic  bronchitis  or  pneumonia  during  the  first  two  or  three  weeks.  Re- 
currence takes  place  at  periods  varv'ing  from  nine  months  upward  (H  a  h  n). 
One  case,  when  last  heard  from,  had  gone  four  years  without  recurrence. 
Recurrences  are  regionar\',  as  a  rule.  The  mortality  following  extirpation  for 
sarcoma  is  somewhat  less,  and  recurrence  is  less  likely  to  occur. 

The  immediate  mortality  following  partial  (one-sided)  extirpation  is  less 
than  that  following  total  laryngectomy.  The  average  length  of  time  before 
recurrence  takes  place  in  both  partial  excision  and  total  excision  varies  with 
the  extent  of  the  disease  and  the  ability  of  the  operator  to  extend  the  extirpa- 
tion of  surrounding  tissues  beyond  the  limits  of  the  growth.  As  in  malig- 
nant disease  elsewhere,  early  interference  is  always  to  be  strongly  urged. 


THE  THYROID  GLAND 

Injuries  of  the  thyroid  gland  occur  almost  exclusively  in  connection 
with  self-inihcted  suicidal  w^ounds.  The  injur}"  inflicted  on  other  parts  is 
usually  more  important  than  that  of  the  thyroid,  though  the  hemorrhage  may 
be  abundant,  particularly  in  the  somewhat  rare  instances  in  which  the  lateral 
lobes  are  reached  by  the  incision  and  the  thyroid  arteries  divided.  The  isth- 
mus may  be  injured  in  the  operation  of  tracheotomy,  and  in  diphtheritic  cases 
may  become  the  site  of  infection. 

Thyroiditis,  or  non-traumatic  inflammation  of  thyroid  tissue,  is  very' 
rare  in  healthy  glands.  It  usually  ends  in  formation  of  abscess.  Pyemic 
infection  and  metastatic  inflammation  of  glands  that  are  the  site  of  goiter  may 
occur  in  connection  with  multiple  pyemia  and  certain  infectious  fevers.  The 
treatment  is  that  of  suppurative  inflammation  in  general. 

Goiter  (Struma,  Bronchocele). — Goiter  may  be  denominated  a  true 
adenoma  of  the  thyroid  gland,  though  the  term  has  been  applied  indiscrimin- 
ately to  all  tumors  of  this  structure.     The  different  varieties  of  goiter  may  be 


THE    THYROID    GLAND  611 

classified  as  folknvs:  (1)  hypertrophy  of  the  gland;  (2)  fetal  adenoma;  (3) 
gelatinous  or  intraacinous  adenoma  (Wolfler).  The  first  consists  in  a 
unit'onn  iiuTcase  in  the  gland  tissue,  is  soft  to  tlie  feel,  and  may  be  vascular  and 
compressible.  The  second  follows  formation  of  gland  tissue  from  the  remains 
of  fetal  structure  in  the  gland  and  is  usually  observed  as  one  or  more  fine  and 
movable  nodules,  varying  in  size  from  a  hazelnut  to  an  orange.  The 
third  consists  in  an  increase  in  size  of  the  acini,  these  being  apparently 
dilated  by  the  accumulation  of  colloid  material  and  the  growth  of  the  intra- 
acinous tissue.  Cystic  goiter  is  a  result  of  further  liquefaction  of  this  colloid 
material;  irregularly  dilated  acinous  spaces  filled  with  straw-colored  semi- 
lic{uid  occur  at  one  or  more  points  in  the  tumor.  Mucous  cysts  are  sometimes 
found  in  the  so-called  accessor}-  thyroid  glands.  These  latter  consist  of  dis- 
placed portions  of  thyroid  tissue,  the  displacement  occurring  during  fetal  life. 
They  are  found  in  the  neighborhood  of  the  hyoid  bone,  where  the  mucous  cyst 
is  most  frequently  found,  at  the  base  of  the  tongue,  behind  the  j^harynx  and 
esophagus,  and  behind  the  sternum. 

Vascular  goiter  may  deserve  clinical  recognition  as  a  distinct  variety, 
though  pathologically  it  is  an  undue  dilatation  of  the  vessels,  especialty  the 
arteries,  which  may  occur  in  any  of  the  forms  of  thyroid  adenoma.  It  is  charac- 
terized by  distinct  pulsation  and  a  perceptible  bruit,  heard  through  the 
stethoscoiDe.  It  may  preserve  the  form  of  the  gland  or  Ijecome  crescentic  in 
shape. 

Finally,  we  may  distinguish  clinically  fibrous,  calcifying  goiter,  and  ossi- 
fying goiter.  These  terms  signify  certain  changes  which  any  of  the  varieties  of 
goiter  may  undergo  in  course  of  time. 

Causes. — The  disease  may  occur  at  any  time  of  life  and  sometimes  develops 
during  pregnancy  (hypertrophy  of  the  gland).  It  occurs  more  f requently . in 
females.  It  has  been  observed  to  develop  after  malaria,  diphtheria,  and 
typhoid  fever.  It  may  be  either  sporadic,  endemic,  or  epidemic.  It  occurs 
endemically  in  certain  mountainous  districts  on  the  continent  of  Europe  and 
in  the  lowlands  of  rivers  as  well.  These  districts  have  a  special  geologic  forma- 
tion, the  w^aters  from  which  consist  largely  of  magnesia  (Grange).  It  has 
been  noticed  to  occur  epidemically  in  schools  and  garrisons  (W  a  r  r  e  n).  The 
special  cause  has  not  been  discovered.  Grange,  followed  by  L  ii  c  k  e  and 
V  i  r  c  h  o  w  ,  attributed  the  disease  to  a  special  miasma,  while  B  i  r  c  h  e  r 
claimed  to  have  discovered  a  special  microorganism  in  the  waters  of  the 
districts  in  w^hich  it  is  endeixiic. 

The  growth  of  goiter  is  extremely  slow.  Occasionally  an  acute  form  is 
observed  (vascular  goiter) ;  it  may  C|uickly  prove  fatal  from  pressure  effects  on 
the  trachea.  In  goiters  of  slow  growth,  sudden  death  may  also  occur  from 
asphyxia,  from  paralysis  of  the  posterior  crico-arytenoid  muscles  due  to  pres- 
sure on  the  recurrent  laryngeal  nerve. 

When  the  goiter  has  advanced  sufficiently  to  cause  stenosis  and  consequent 
d3'spnea,  the  further  growth  is  greatly  accelerated  b}'  congestion  in  the  venous 
channels.  This  is  shown  by  the  decided  diminution  in  size  of  the  enlargement 
within  a  few  hours  after  a  tracheotomy,  a  long  tube  being  used. 

Finally,  an  inflammatory  swelling  of  the  goiter  (striunitis,  K  o  c  h  e  r)  may 
produce  a  dangerous  degree  of  tracheal  stenosis.  The  inflammation  may  occur 
in  connection  with  infectious  diseases  in  septicemia  and  pyemia  or  it  ma}^  arise 


612  SURGERY   OF  THE   NECK 

witliout  discoverable  cause  and  follow  febrile  catarrhal  conditions  of  mucous 
membranes.  If  not  arrested  early  by  the  application  of  antiphlogistic  remedies 
and  the  injection  of  a  5  per  cent  solution  of  carbolic  acid  (K  o  c  h  e  r),  extensive 
sujipuration  and  gangrene  may  occur. 

The  Relation  of  Goiter  to  Cretinism. — Cretinism  is  characterized  by 
idioc>'  and  imjierfect  development  of  the  bones,  particularly  those  of  the  skull. 
]ioth  affections  are  found  in  the  same  localities  and  sometimes  in  the  same 
intlividuals.  In  addition  to  this,  it  has  been  shown  by  statistics  that  half  the 
number  of  cretins  in  these  districts  originate  from  parents  who  have  goiter. 

Exophthalmic  Goiter  (Graves's  Disease).— This  is  a  sporadic  form 
of  the  disease  ciuiraeterized  by  a  peculiar  coml)ination  of  palpitation  of  the 
heart  (tachycardia),  exophthalmos,  and  thyroid  enlargement.  The  condi- 
tion is  supposed  to  have  its  origin  in  local  nerve  irritation  giving  rise  to  perverted 
function  and  finally  to  toxic  effects  from  altered  thyroid  secretion  (Green- 
field,  Mandiy. 

Temporary  enlargement  of  the  thyroid  gland  bears  a  certain  relation  to 
the  female  sexual  life  and  appears  at  the  time  of  menstruation.  It  depends  on 
some  obscure  vasomotor  influences. 

Embolic  distribution  of  portions  of  goiter,  these  prohferating  in  the  thyroid 
veins,  particles  ]3eing  swept  in  the  blood-current  and  producing  tumors  at  dis- 
tant points,  particularly  in  the  medullary  tissue  of  the  bones  of  the  extremities 
(W .    M  ii  1 1  e  r  ,  Neumann),  has  been  observed. 

The  diagnosis  of  goiter  is  not  difficult,  as  a  rule.  It  is  to  be  differentiated 
from  all  other  tumors  in  this  region  by  the  fact  that  it  moves  up  and  down  with 
each  act  of  swallowing.  The  only  other  tumor  which  presents  this  symptom  is 
a  hydrops  of  the  thyrohyoid  bursa  mucosa.  Nor  is  it  difficult  to  differentiate 
the  different  varieties,  both  pathologically  and  clinically.  Disturbances  of 
function  are  not  in  proportion  to  the  size  of  the  goiter.  Large  growths  may  give 
rise  to  very  shght  disturbances  and  small  growths  to  pronounced  symptoms. 
Disturbances  of  deglutition  are  rare,  except  in  cases  where  the  disease  attacks 
displaced  portions  of  thyroid  tissue  behind  the  pharynx  or  esophagus 
(Czerny,  Kocher).  Disturbed  respiration  depends  on  the  relation 
which  the  mass  bears  to  the  trachea.  This  may  also  occur  in  those  cases  in 
which  the  affection  is  present  in  a  portion  of  thyroid  situated  behind  the 
sternum.  These  so-called  "plunging  goiters"  make  a  rapid  downward  move- 
ment behind  the  sternum  during  an  act  of  inspiration  and  compress  the  trachea, 
to  reappear  during  expiration.  Goiters  which  grow  backward  easily  compress 
the  trachea  from  the  fact  that  from  one-fifth  to  one-third  of  the  periphery  of  the 
tube  is  uncovered  by  cartilage  behind;  respiration  is  interfered  with  early  in 
these  cases.  Lateral  compression  of  the  trachea  between  the  enlarged  lobes 
also  interferes  greatly  with  respiration,  producing  the  so-called  "scabbard 
trachea." 

The  Treatment  of  Goiter. — The  external  apphcation  of  tincture  of 
iodin,  as  well  as  of  ointments  of  iodid  of  potassium  formerly  much  in  vogue,  is 
now  very  generally  deemed  useless.  The  internal  use  of  iodid  of  potassitun 
has  much  to  recommend  it.  It  should  be  continued  for  months,  being  inter- 
rupted only  because  of  intolerance  of  the  drug,  as  shown  by  the  symptoms  of 
iodism. 

A  certain  degree  of  success  is  obtained  by  the  use  of  injections  of  tincture 


TIIK    THYROID    GLAND  613 

of  iodin  (1>  u  t  o  n  and  1.  ii  c  k  c).  From  10  to  15  drops  of  the  tincture  is 
injected,  with  antisejitic  j^recautions,  into  the  tumor  every  tliird  or  fourth  day. 
The  accidental  entrance  of  the  injected  tincture  into  a  large  blood-vessel  is 
followed  b}'  alarming  symptoms  of  dizziness  and  fainting.  This  is  to  be  guarded 
against  by  first  introducing  the  detached  needle  and  directing  the  patient  to 
make  movements  of  swallowing.  If  a  large  vessel  has  been  entered,  the  drops 
of  blood  will  follow  one  another  in  quick  succession  through  the  needle,  and 
another  place  must  be  selected  for  the  injection.  The  barrel  of  the  syringe, 
previously  charged,  may  then  be  screwed  fast  to  the  needle  and  the  injection 
made.  Strumitis  terminating  in  suppuration  occurring  as  a  result  of  the  injec- 
tion is  due  to  uncleanly  manipulation.  The  method  is  applicable  only  to 
simple  hypertrophic  goiter.  It  is  useless  in  goiters  that  have  undergone 
fibrous,  calcifying,  or  ossifying  changes;  it  is  contraindicated  in  the 
gelatinous  variety  and  is  highly  dangerous  in  vascular  growths. 

The  injection  of  alcohol  (Schwalbe)  is  inferior  to  that  of  tincture  of  iodin. 
Injections  of  arsenic  have  not  fulfilled  the  expectations  of  its  originator.  In 
Graves's  disease  a  solution  of  extract  of  ergot  to  which  carbolic  acid  has  been 
added,  injected  into  the  connective  tissue  of  the  anterior  region  of  the  neck  and 
not  into  the  goiter  itself,  has  been  followed  by  favorable  results  (C  a  g  h  i  1 1). 

In  cystic  goiter,  where  a  single  C3^st  can  be  isolated  and  emptied  by  the 
trocar  and  cannula,  this  may  be  follow^ed  by  an  injection  of  from  15  to  30  drops 
of  tincture  of  iodin.  As  this  form  of  goiter  is  usually  a  further  stage  of  develop- 
ment of  the  gelatinous  or  intraacinous  variety,  there  is  considerable  danger  of 
setting  up  acute  suppuration.  The  occurrence  of  this  M-ill  necessitate  incision 
or  extirpation. 

The  Operative  Treatment  of  Goiter. — Treatment  by  setons  has  been  aban- 
doned. Attempts  at  cure  by  electrolysis  are  unsafe  and  have  proved  to  be  of 
but  slight  benefit  when  employed.  Opening  cystic  goiters  by  the  use  of 
chlorid  of  zinc  paste  is  mentioned  only  to  be  condemned. 

Incision  is  indicated  in  suppurative  inflammation  and  possibly  in  some  cases 
of  cystic  goiter.  To  avoid  dangerous  hemorrhage  the  opening  may  be  carefully 
made  with  the  thermocautery.  Even  with  this  precaution  there  may  be  serious 
hemorrhage  from  the  presence  of  vascular  tissue  in  the  cyst  wall  itself.  The 
bleeding  may  be  controlled  by  passing  acupuncture  needles  across  the  base  of 
the  tumor  and  appljdng  a  constricting  ligature  beneath  these.  Where  the  cyst 
is  quite  superficial,  it  may  be  opened  under  asepsis  with  the  knife,  and  the  sac 
wall  and  skin  stitched  together. 

Extirpation. — Owing  to  improved  methods  of  hemostasis  and  asepsis,  the 
radical  cure  of  goiter  by  extirpation  has  become  an  established  operation.  It 
is  to  be  recommended  in  progressive  cases  in  which  iodin  injections  have  failed, 
and  may  replace  incision  in  cases  of  cystic  goiter  demanding  interference.  Total 
extirpation  of  the  thyroid  gland  is  contraindicated  b}^  the  prol^ability  of  the 
occurrence  of  cachexia  strumipriva.  The  operative  methods  available  are 
(1)  excision;  (2)  enucleation;  (3)  resection. 

Excision  (K  o  c  h  e  r).— Disfiguring  may  be  avoided  by  the  use  of  the 
transverse  curved  or  "  collar  "  incision,  with  the  concavity  directed  up- 
ward (Fig.  363).  This  is  carried  across  the  most  prominent  part  of  the  swelling. 
The  skin  and  platysma  are  divided  and  branches  of  the  anterior  jugular  vein 
cut  across  between  two  ligatures.     The  fibers  of  the  sternolaryngeal  muscles, 


614 


SURGKRY    OF   THE    NECK 


Fig.  363. — Kocher's  Curved  (Collar)  Incision 
FOR  Goiter. 


sometimes  greatly  thinned,  are  exposed  and  separated  vertically-  or  diA'ided  in 

the  line  of  the  skin  incision.  When 
necessary,  the  anterior  edge  of  the  cor- 
responding sternomastoid  is  nicked, 
when  the  tumor  is  freely  exposed. 

When  the  tumor  is  large  and  it  is 
(lesiral^le  to  avoid  extensive  division  of 
the  muscles,  the  angular  incision  is  to 
be  employed  (Fig.  365).  This  begins 
over  the  prominence  of  the  sternomas- 
toid at  the  level  of  the  thyroid  carti- 
lage and  extends  almost  transversely  in 
the  direction  of  the  skin-creases  as  far 
as  the  middle  line  of  the  neck,  and 
thence  vertically  downward  to  the 
suprasternal  region.  In  deeply  situ- 
ated goiters  it  is  prolonged  on  to  the 
manubrium  sterni.  The  skin  and 
platysma  are  divided  in  the  transverse 
portion  of  the  incision.  The  superficial 
fascia  is  now  divided.  The  anterior 
jugular  vein  is  divided  between  two 
ligatures.  The  anterior  border  of  the 
sternomastoid  is  exposed  at  the  outer 
extremity  of  the  horizontal  incision  and  thoroughly  freed  and  drawn  aside  with 
blunt  retractors.  The  fascia  at  the 
middle  portion  of  its  horizontal  incis- 
ion is  retracted  and  the  fibers  of  the 
sternohyoid  and  sternothyroid  ex- 
posed. The  two  sets  of  sternolaryn- 
geal  muscles  lying  on  each  side  are  now 
separated  in  the  vertical  portion  of  the 
incision,  freed,  lifted  up  by  passing  the 
finger  beneath  them,  and  partially  or 
completely  divided  and  retracted  by 
blunt  hooks. 

The  thin  layer  of  connective  tissue 
which  constitutes  the  outer  capsule  of 
the  gland  is  now  carefully  divided  and 
stripped  to  each  side  by  blunt  dissec- 
tion; any  veins  which  pass  from  the 
capsule  to  the  goiter  are  divided  be- 
tween two  ligatures.  The  capsule  and 
overlying  muscular  structures  are  re- 
tracted, the  finger  passed  around  the 
outer  edge  of  the  tumor,  and  the  latter 
carefully  detached  until  the  finger 
reaches  the  posterior  surface. 

The  tumor  is  now  drawn  forward  and  the  principal  vessels  hgated.     The 


Fig.    364. — Goiter.     Curved    Incision. 
CLES  Exposed. 


Mus- 


THE    THYROID    GLAND 


615 


relations  of  the  recurrent  laryngeal  nerve  to  the  inferior  thyroid  artery  are  such 
as  to  endanger  this,  unless  the  artery  is  carefully  isolated  and  insjjected  before 
tying.  Unless  the  operator  is  enabled  positively  to  identify  the  nerve,  only  a 
provisional  ligature  should  be  applied. 

The  further  isolation  of  the  tumor  is  now  proceeded  with.  The  large  inferior 
thyroid  vein  or  its  branches  is  put  upon  the  stretch  and  divided  between  two 
ligatures.  The  superior  thyroid  artery  is  exposed  l^y  blunt  dissection  above 
the  isthmus.  The  dissection  is  carried  upward  along  the  inner  border  of  the 
upper  horn,  which  is  lifted  carefully  forward,  and  a  ligature  passed  beneath  the 
superior  thyroid  vessels,  which  are  tied  and  divided.  The  isthmus  is  now  care- 
fully isolated  and  a  strong  silk  ligature  passed  by  means  of  a  large  aneurism 
needle,  or  Thiersch's  ligature  carrier  and  spindle,  and  tightened  while  the 
isthmus  is  being  divided.  The  goiter  is  now  lifted  away  from  the  trachea,  to 
which  its  posterior  border  is  still  at- 
tached. In  detaching  the  tumor  from 
the  trachea  at  this  point,  the  recurrent 
laryngeal  nerve  is  in  danger  of  being 
injured  in  spite  of  every  care.  In  order 
to  guard  against  this,  it  is  better  for 
the  surgeon  to  cut  through  the  tumor 
parallel  to  the  surface  of  the  trachea, 
leaving  behind  a  portion  of  the  in- 
ternal capsule.  If  the  nerve  has  not 
been  included  in  the  ligation  of  the 
inferior  thyroid,  the  tumor  can  now 
be  completely  removed.  Otherwise 
another  ligature  must  be  applied  and 
the  first  removed,  after  which  the  re- 
maining attachments  may  be  divided. 
The  thermocautery  may  be  employed 
to  effect  the  separation  of  the  goiter 
at  the  isthmus,  the  silk  Hgature  being 
dispensed  with. 

Enucleation  (Porta,  Soc- 
i  n). — This  is  applicable  where  single, 
large  colloid  or  cystic  nodules  are  to  be 

removed.  In  these  cases  it  is  a  simpler  procedure  than  excision  and  possesses 
the  additional  advantage  of  preserving  the  healthy  thyroid  tissue.  The  tumor 
is  to  be  exposed  as  in  K  o  c  h  e  r '  s  operation,  after  which  the  healthy  thyroid 
(internal  capsule)  over  the  nodules  is  incised  and  the  latter  shelled  out.  The 
hemorrhage  is  sometimes  severe.  To  prevent  this,  the  main  vessels  may  be 
ligated  preliminarily. 

Resection  of  Goiter  {M  i  k  u  1  i  c  z). — This  consists  of  resecting  the  diseased 
part  of  the  gland.  It  can  be  only  exceptionally  applied,  and  should  be  resorted 
to  only  in  cases  in  which  the  nodules  are  small  and  prominent  and  easily  separa- 
ble, or  in  cases  of  diffuse  colloid  degeneration  in  which  the  mass  is  not  easily 
lifted  forT\'ard  for  purposes  of  excision.  Ligation  of  the  vessels  on  one  side 
should  precede  the  resection  in  these  cases.  The  thyroid  tissue  is  sometimes 
very  brittle  and  pressure  forceps  applied  as  angiotribes  cut  into  it  and  cause 


Fig.  365. — Goiter.     Angular  Incision. 


616  SURGERY   OF   THE   NECK 

severe  hemorrhage.     The  wound  tlocs  not  heal  so  readily  as  in  typic  excision 
on  account  of  the  large  stumps  of  ligated  tissue  which  become  necrotic. 

Enucleation  Resection  (Kocher). — The  goiter  is  exposed  as  before, 
ligation  of  the  main  vessels,  however,  being  omitted.  The  tumor  is  drawn 
forward  and  the  isthmus  ligated  and  di\'ided.  Access  is  gained  to  the  nodule 
through  the  cut  surface  of  the  divided  isthmus.  The  gland  capsule  is  separated 
by  blunt  dissection  and  ])ressure  forceps  appUed  in  an  upward  and  downward 
direction.  The  tissues  included  in  the  forceps  are  then  ligated,  the  forceps  being 
gradually  loosened  as  the  Ugatures  are  tightened.  It  may  be  necessary  to 
repeat  this  maneuver  in  the  neighborhood  of  the  upper  and  lower  poles.  The 
posterior  wall  of  the  capsule  is  now  incised  vertically  and  the  parts  beyond  the 
ligatures  enucleated. 

In  closing  the  wound  after  thyroidectomy  the  head  should  be  flexed  slightly 
forward,  the  divided  portions  of  the  sternolaryngeal  muscles  united  by  chromi- 
cized  catgut,  and  the  external  skin  wound  closed  by  the  intracuticular  or  the 
chain  suture. 

When  extirpation  of  goiter  is  performed  on  account  of  great  difficulty  of 
breathing,  general  anesthesia  should  be  avoided,  when  possible.  Local  cocain 
anesthesia  aided  by  morphin  narcosis  is  to  be  preferred  in  such  cases  (K  o  c  h  e  r). 

Summary  of  important  points  in  the  operation  of  thyroidectomy: 
(1)  Avoid  resort  to  general  anesthesia,  as  a  rule.  (2)  Emplo}'  cocain  and  mor- 
phin whenever  practicable.  Among  other  advantages  there  is  less  danger  of 
hgating  the  recurrent  laryngeal  nerve;  the  patient  should  be  asked  to  count 
aloud  when  the  attempt  is  made  to  secure  vessels  in  the  neighborhood  of  the 
nerve.  (3)  Sensitive  patients  with  healthy  chest  organs  may  have  ether  or 
chloroform,  if  they  urgently  insist  on  it,  during  the  operation.  (4)  Avoid  anti- 
septics. Strict  asepsis  is  to  be  established  and  maintained  during  the  operation. 
(5)  Make  all  incisions  free,  and,  as  far  as  possible,  in  the  direction  of  the  natural 
creases.  (6)  !\Iake  a  timely  and  careful  ligation  of  the  vessels  before  division, 
thus  insuring  against  excessive  loss  of  blood  and  injury  of  the  recurrent  laryn- 
geal nerve,  whose  location  is  masked  by  the  flooding  of  the  field  of  operation, 
and  secondary  hemorrhage.  (7)  The  sternolaryngeal  muscles  and  their  nerve- 
supply  should  be  considerately  treated  and  disturbed  as  little  as  possible,  else 
sinking  in  of  the  neck  will  follow.  When  necessary  to  divide  the  muscles,  this 
should  be  done  near  their  upper  insertion. 

The  occurrence  of  cachexia  strmnipriva  (Kocher),  or  myxedema, 
following  total  removal  of  goiter  is  characterized  in  the  beginning  by  a  sensation 
of  general  weariness  and  a  sense  of  weight  and  coldness  in  the  extremities. 
The  movement  of  the  limbs  becomes  slow  and  heavy  and  the  speech  is  clumsy. 
The  skin  becomes  bloated  in  appearance,  particularly  in  the  face,  and  this, 
together  with  the  pallor  and  dullness  of  expression,  gives  an  idiotic  appearance 
to  the  patient.  Mental  powder  and  energy  are  lessened,  and  patients  are  unable 
to  continue  their  former  occupations.  The  young  are  stunted  in  their 
growth.  A  general  condition  of  hydremia  is  present,  the  skin  and  mucous 
membranes  becoming  markedly  pale.  The  skin  is  everywhere  edematous. 
The  proportion  of  red  corpuscles  is  lessened  in  the  majority  of  cases.  The  im- 
pulse in  the  vessels  is  remarkably  lessened.  The  entire  clinical  picture  resem- 
bles the  condition  described  as  "cretinoid  disease"  (Gull),  "myxedema" 
(Ord),  and  "pachydermatous  cachexia"  (Charcot).     The  resemblance  is 


Till':    ESOPHAGUS 


617 


still  further  augmented  l\v  the  fact  that  the  decrease  in  size  of  the  thyroid  gland 
is  a  marketl  and  permanent  feature  in  myxedema. 

Typic  cachexia  strumipri\'a  occurs  only  after  extirpation  of  the  entire 
thyroid  gland.  It  follows  the  operation  about  twice  as  often  in  males  as  in 
females.  The  occurrence  of  tetany  has  also  been  observed  to  follow  total  extir- 
pation of  the  thyroid  (W  e  i  s  s  ,  B  i  1 1  r  o  t  h  ,  M  i  k  u  1  i  c  z). 

Paralysis  of  one  recurrent  laryngeal  nerve  from  injury  or  contusion  of 
the  nerve  during  the  operation  not  uifrcquently  occurs.  Hoarseness  follows, 
and  deglutition  may  be  erratic  on  account  of  paresis  of  the  epiglottis,  particles 
of  food  passing  into  the  glottis.  Paralysis  of  the  corresponding  vocal  cord  is 
revealed  by  the  laryngoscope.  The  breathing  is  not  disturbed  unless  the  paral- 
ysis is  bilateral,  the  accident  is  sometimes  unavoidable.  It  is  to  be  noted 
that  the  condition  is  sometimes  present  before  the  operation,  and  the  latter 
may  relieve  it.  In  any  event,  the  voice  usually  improves,  though  laryngo- 
scopic  examination  still  reveals  paralysis  of  the  vocal  cord. 

Sarcoma  of  the  thyroid  gland  sometimes  develops,  partly  in  old  goiters, 
partly  in  normal  tissue!  It  is  characterized  by  rapid  and  enormous  increase  in 
the'size  of  the  gland. 

Carcinoma  occurs  either  in  the  medullary  form  with  development  of  large 
soft  masses  in  the  tumor,  or  in  the  scirrhous  form,  in  which  there  is  shrinkage  of 
the  connective-tissue  stroma,  induration,  and  gradual  decrease  in  the  size  of  the 
growth.  It  is  a  disease  of  great  rarity,  except  in  districts  where  diseases  of  the 
thyroid  are  prevalent.  It  occurs  between  the  ages  of  forty  and  fifty.  In  the 
early  stages  of  the  disease  it  may  greatly  resemble  an  ordinary^  goiter.  The 
steady  increase  in  the  size  of  the  gland,  its  nodulated  outline,  the  occurrence 
of  pain,  and  paralysis  of  the  recurrent  laryngeal  nerve  as  infiltration  proceeds, 
together  with  a  certain  fixity  of  the  gland,  constitute  the  characteristic 
symptoms.  Disturbances  of  respiration  and  radiating  pains  are  said  to  be 
pathognomonic  of  fibrous  carcinoma  or  scirrhus  of  the  thyroid  gland. 

Dissemination  takes  place  rarely,  unless  the  condition  known  as  general 
thyroid  malignancy,  described  by  C  o  h  n  h  e  i  m  ,  constitutes  an  expression  of 
such  dissemination  occurring  in  connection  with  the  very  eariiest  stages  of  over- 
looked cancer  of  the  thyroid.  In  the  condition  in  question,  tumors  structurally 
identical  with  the  thyroid  gland  are  formed  in  the  bones  in  individuals  affected 
with  enlargement  of  the  gland.  These  growths  appear  more  frequently  in  women 
than  in  men.  Cases  have  been  reported  in  which  tumors  were  found  on  the 
bones  of  the  skull,  for  which  they  seem  to  have  a  predilection.  They  have  also 
been  found  in  the  following  situations,  mentioned  in  the  order  of  frequency  of 
occurrence  of  the  tumors:  the  femur,  clavicle,  sternum,  and  vertebrae.  The 
growths  may  attain  a  considerable  size,  and  in  some  instances  pulsation  has 
been  a  marked  feature. 

Operative  treatment  in  these  secondary  tumors,  when  they  have  appeared 
in  accessible  situations,  has  been  followed  by  satisfactory  results. 

THE  ESOPHAGUS 
Injuries.— Of  injuries  of  the  esophagus  the  majority  are  incised  wounds; 
gunshot  wounds  are  observed  next  in  frequency  and  punctured  wounds  least 
of  all.     The  first  occur  almost  exclusively  in  connection  with  suicidal  attempts. 


618  SURGERY   OF   TIIK    NECK 

The  prognosis  in  this  class  of  cases,  other  things  Ijeing  equal,  is  in  proportion  to 
the  extent  of  the  separation.  Tracheotomy  is  at  once  performed  and  the  wound 
in  the  esophagus  closed  with  chromicized  catgut.  The  patient  is  fed  by  means 
of  a  stomach  tul^e.  In  transverse  separation  of  the  larynx  and  esophagus  the 
wound  may  gape  widely  in  spite  of  every  effort,  a  permanent  fistula  becoming 
established.     A  plastic  operation  may  be  necessary  to  cure  the  defect. 

Punctured  and  shot  wounds  of  the  esophagus  alone  are  rare.  The  latter 
is  usuall}-  injured  from  the  side.  In  all  of  these  cases  the  swallowed  food  escapes 
through  the  wound  for  a  short  time  only,  the  latter  finally  closing  by  granulation 
and  cicatrization.  In  order  to  prevent  phlegmonous  inflammation  of  the  con- 
nective-tissue planes  of  the  neck  from  lodgment  of  food  in  the  wound  track  the 
patient  should  be  fed  by  the  stomach  tube  until  granulations  are  formed. 

Transverse  rupture  of  the  esophagus  from  forcible  efforts  at  vomiting  has 
been  observed  (B  o  e  r  h  a  v  e).     Death  usually  follows  from  mediastmitis. 

Injuries  from  swallowing  caustic  substances  derive  their  chief  surgical 
importance  from  the  cicatricial  stenosis  of  the  tube  which  subsequently 
follows.  In  the  case  of  acids  the  immediate  treatment  consists  in  the  adminis- 
tration of  harmless  alkalis,  such  as  chalk  or  lime  water;  and  in  the  case  of 
alkalis,  vinegar  or  fniit  acids. 

Instrumentation  of  the  Esophagus. — The  use  of  the  esophageal 
bougie  is  of  service  in  the  diagnosis  of  diseased  conditions  of  the  esophagus. 
By  means  of  it,  altered  conditions  of  the  wall  of  the  esophagus  may  be  quite 
satisfactorily  made  out. 

The  stomach  tube  is  employed  for  purposes  of  artificial  feeding.  The 
instrument  is  best  made  of  thick-walled  rubber  tubing,  with  a  smooth-edged 
extremity,  or  a  lateral  velvet-edged  opening  near  the  end. 

Before  introducing  the  stomach  tube  the  distance  from  the  lips  to  the  hypo- 
chondrium  should  be  measured,  in  order  to  avoid  introducing  the  tube  too  far. 
In  the  normal  esophagus  the  tube  is  arrested  at  a  point  directly  behind  the 
cricoid  cartilage,  at  which  point  the  latter  approaches  the  vertebral  column.  In 
order  to  overcome  this  resistance  the  larynx  is  drawn  forward  by  placing  the 
tip  of  the  index-finger  of  the  left  hand  in  the  depression  between  the  epiglottis 
and  the  tongue,  and  drawing  the  parts  forward  through  the  medium  of  the 
glosso-epiglottic  ligament.  Simply  bending  the  finger  sharply  against  the  base 
of  the  tongue  usually  suffices,  the  point  of  the  tube  being  at  the  same  time 
directed  toward  the  posterior  pharyngeal  wall  and  passed  downward.  The 
patient  is  then  directed  to  make  efforts  at  swallowing.  The  tube  passes  without 
further  resistance  into  the  esophagus.  For  purposes  of  artificial  feeding,  the 
tube  is  connected  to  a  glass  funnel.  The  fluid  must  be  introduced  slowly,  other- 
wise efforts  at  vomiting  will  be  provoked.  In  cases  of  injury  of  the  pharynx 
and  esophagus,  and  after  certain  operations  about  the  neck  (extirpation  of  the 
larjmx,  etc.),  the  frequent  introduction  of  the  stomach  tube  may  do  harm. 
Retention  of  the  tube  in  situ  by  means  of  a  safety-pin  passed  through  its  wall, 
to  which  a  tape  is  secured  and  passed  around  the  neck  and  tied  over  the  dress- 
ings, is  here  indicated. 

The  stomach  tube  is  also  used  for  washing  out  the  stomach  (lavage),  the 
fluid  which  has  been  introduced  being  withdrawn  by  simply  lowering  the  glass 
funnel  to  which  it  is  connected  just  before  it  is  empty.  The  tubing  which  con- 
nects the  funnel  to  the  stomach  tube  being  longer  than  the  portion  which  occupies 


THE    ESOPHAGUS 


619 


the  esophagus,  a  siphon  effect  is  produced  and  the  stomach  is  promptly 
emptied.  It  may  be  refilled  and  emptied  in  this  manner  as  often  as  required. 
When  the  patient  resists,  as  the  insane,  a  proper  sized  tube  may  be  passed 
through  the  nasal  cavity  and  thence  to  the  stomach.  In  children  a  gag  may  be 
used.  If  this  is  not  at  hand,  the  operator  may  avoid  injury  of  his  finger  from 
the  little  patient's  teeth  by  forcing  the  lip  in  with  the  finger.  The  patient 
then  l)ites  his  own  hp. 

Foreign  Bodies  in  tlie  Esophagus.— Round,  smooth  foreign  bodies 
that  have  been  swallowed  usually  find  their  way  without 
difficulty  into  the  stomach,  and,  in  the  course  of  time,  are 
passed  per  anum.  When  retained,  however,  their  retention 
is  due  to  convulsive  contractions  of  the  tube,  the  foreign 
body  being  arrested  either  behind  the  cricoid  or  at  the  car- 
diac orifice.  In  children  pieces  of  coin,  buttons,  etc.,  are 
swallowed  and  lodged  in  the  esophagus.  Pins  carelessly 
held  between  the  teeth  sometimes  find  their  way  into  the 
mouth  and  are  swallowed.  Imperfectly  masticated  pieces 
of  meat,  bones  taken  with  the  food,  and,  finally,  artificial 
teeth  have  been  lodged  in  the  esophagus.  These  latter  may 
produce  fatal  suffocation  by  pressure  on  the  trachea.  One- 
fourth  of  the  fatal  cases  of  foreign  bodies  in  the  esophagus 
perish  from  asphyxia  (K  6  n  i  g) . 

Wounds  of  the  esophagus  from  pointed  and  angular 
foreign  bodies  are  particularly  dangerous.  Pins  and 
needles  may  perforate  the  tube,  migrate  from  muscular 
action,  and  enter  a  large  vessel  (aorta,  carotid),  causing 
death  from  hemorrhage.  Those  perforating  low  down 
may  enter  the  heart.  A  bronchus  may  be  invaded.  They 
may  appear  beneath  the  skin  of  the  neck  and  be  removed 
by  a  simple  incision.  Artificial  teeth  on  plates  with  pro- 
jecting angles,  bits  of  glass,  pieces  of  bone,  etc.,  wound  the 
tube  in  their  passage  downward  and  produce  ulceration  or 
necrosis  from  pressure.  The  wall  of  the  esophagus  is  per- 
forated, food  enters  the  periesophageal  connective  tissue, 
and  extensive  and  fatal  suppuration  frequently  follows. 
The  mediastinal  space,  or  the  pleural  cavity,  may  thus 
become  the  seat  of  suppurative  inflammation.  The  trachea 
may  be  invaded,  an  esophageotracheal  fistula  resulting, 
with  fatal  termination. 

The  diagnosis  of  foreign  bodies  is  to  be  based  on  the  his- 
tory, the  existing  difficulties  of  swallowing,  and  particularly  the  results  of  exam- 
ination by  means  of  the  esophageal  bougie.  It  sometimes  happens  that  the 
foreign  body  has  passed  into  the  stomach  and  the  symptoms  are  due  to  injuries 
inflicted  during  the  passage.  MetaUic  foreign  bodies,  if  not  completely  em- 
bedded, may  be  located  by  means  of  the  Rontgen  rays  or  the  telephone  probe. 
Treatment.— Large  masses  of  meat,  etc.,  as  wefl  as  smooth  bodies,  are  to  be 
pushed  into  the  stomach  by  means  of  a  whalebone  bougie  with  a  piece  of  com- 
pressed sponge  attached. 

This  instrument  may  be  used  for  both  propulsion  and  extraction.     When 


Fig.  366. — Graefe's 
Coin  Catcher. 


620 


SURGERY   OF   THE   NECK 


for  the  former,  it  is  passed  down  to  the  mass  and  there  allowed  to  swell  and  fill 
the  entire  esophagus.  When  used  for  extracting  a  foreign  body,  it  is  passed 
below  the  latter,  and,  after  swelling,  is  withdrawn. 

All  pointed  and  angular  bodies  must  be  removed  from  above.  Fish-bones, 
unless  very  large,  seldom  do  harm  after  reaching  the  stomach,  the  gastric  juice 
attacking  and  softening  them.  While  most  swallowed  coins  will  pass  through 
the  entire  intestinal  tract  without  doing  harm,  yet  it  is  best  to  extract  them 
when  possible.     The  instnmient  of  G  r  a  e  f  e  is  useful  for  this  purpose  (Fig. 


■jjl'l,l:u:i};!..ll"niun::uin,ujLnnini,.,ni.mmimnr, 


^ 


Fig.  367. — Flexible  Esophageal  Forceps. 


MrH^^MMMHWHWaiaBiflHBiHiii 


Fig.  368. — Umbrella  Probang  Closed  for  Introduction. 


Oh« 


OriiMAiiiHMHaiHiiMiiteAiiiMlllaliM^^ 


Fig.  369. — Umbrella  Probang  Open  for  Extraction. 


Fig.  370. — Esophageal  Forceps,  Blade  Opening  Laterally. 


Fig.  371. — Curved  Alligator  Forceps. 


366).  The  basket  attachment  should  be  as  wide  as  the  esophagus  will  admit. 
The  flexible  esophageal  forceps  is  also  a  useful  instrument  (Fig.  367).  The 
umbrella  probang  (8  ay  re, Weiss,  Fig.  368)  serves  for  the  extraction  of 
fish-bones,  etc.  It  sometimes  happens  that,  by  means  of  this  instrument,  a  fish- 
bone may  be  loosened  and  placed  longitudinally  in  the  esophagus,  passing  sub- 
sequently to  the  stomach.  For  foreign  bodies  high  up,  forceps  with  blades 
opening  laterally  are  to  be  preferred  (Fig.  370),  for  the  reason  that  this  form 
will  accommodate  itself  best  to  the  longest  diameter  of  the  esophagus. 

In  extracting  foreign  bodies  from  the  esophagus  the  index-finger  of  the  left 


THE    ESOPHAGUS  621 

hand  should  be  passed  to  the  base  of  the  tongue  ready  to  steady  the  foreign  body 
as  it  enters  the  pharynx,  and  prevent  it  from  falling  into  the  glottic  opening. 
Cocainization  of  the  accessible  parts  will  assist  in  the  manipulation.  The 
grasj)ing  and  extraction  of  a  metallic  foreign  ])ody  may  be  accomplished  under 
the  guidance  of  the  .r-ra.ys.  (For  cutting  operations  for  the  removal  of  foreign 
bodies,  see  Esophagotomy.) 

STRICTURES,  TUMORS,  AND  DIVERTICULA  OF  THE  ESOPHAGUS 

Strictures  arising  from  syphilitic  and  tuberculous  ulceration  are  exceed- 
ingly rare.     Esophagitis  in  the  proper  sense  scarcely  ever  exists. 

Cicatricial  strictures  are  commonly  a  late  effect  of  swallowing  caustic 
fluids.  A  slough  is  cast  off  and  gradual  condensation  of  the  resulting  cicatrix 
produces  stenosis.  Weeks  and  in  some  cases  months  may  elapse  before 
s3'mptoms  of  obstruction  appear. 

Epithelial  carcinoma  is  a  frequent  cause  of  stenosis  of  the  esophagus.  It 
usually  occurs  at  the  level  of  the  cricoid  cartilage.  The  next  most  frequent 
points  of  attack  are  near  the  cardiac  orifice,  and  at  the  point  where  the  tube  is 
crossed  b}-  the  left  l^ronchus.  It  is  most  common  iDetween  the  ages  of  forty  and 
sixty.  Of  the  cases,  75  per  cent  occur  in  men.  Lymphatic  glandular  infection 
occurs  at  the  root  of  the  neck,  in  the  mediastinum,  or  in  the  lumbar  region, 
according  to  the  point  of  location  of  the  disease. 

The  disease  is  insidious  in  its  first  symptoms,  but  runs  a  rapid  course,  death 
resulting  from  inanition  due  to  obstruction,  from  septic  pneumonia  and  pleurisy 
following  perforation  of  the  trachea,  or  from  mediastinal  abscess  and  perforation 
of  the  pleura  or  of  the  pericardium.  Two  or  more  points  of  stricture  may  be 
present  from  longitudinal  extension  of  the  disease.  The  diagnosis  is  established 
with  the  aid  of  the  whalebone  bougie  a  boule.  If  ulceration  has  taken  place, 
evidences  of  this  may  be  present  on  the  bougie  when  withdrawn. 

Fibromas  and  myxomas  may  grow  from  the  mucous  membrane  and  become 
pediculated  from  acts  of  swallowing  (polypi  of  the  esophagus).  They  occur 
by  preference  behind  the  cricoid  cartilage.  Deglutition  is  interfered  with,  and 
respiration  as  well,  particularly  when  the  polypus,  being  forced  upward,  lies 
across  the  glottic  opening.  These  growths  are  best  dealt  with  by  being  hfted  up 
in  the  act  of  vomiting,  after  an  emetic  has  been  administered,  and  seized  with 
forceps  and  severed  by  means  of  the  galvanocautery  loop.  If  removed  with 
the  scissors,  the  pedicle  must  first  be  ligatecl  to  avoid  troublesome  hemorrhage. 

Compression  of  the  esophagus  may  result  from  the  pressure  of  tumors 
from  without,  particularly  in  cases  of  carcinomatous  goiter. 

Diverticula  are  mainly  of  congenital  origin  and  may  bear  some  relation  to 
congenital  fistula  of  the  neck  (B  a  r  d  e  1  e  b  e  n).  They  develop,  or  may  even 
originate,  late  in  life.  Anatomically  they  may  consist  of  both  mucous  mem- 
brane and  the  muscular  coat,  or  the  former  may,  hernia-like,  pass  through  an 
opening  in  the  latter.  Dilatation  of  the  esophagus  (ectasia)  may  take  place 
in  connection  with  stricture  from  any  cause  or  independently  of  this.  Spasm 
of  the  cardiac  orifice  having  its  origin  in  reflex  neurotic  disturbances  or  occurring 
as  a  hysteric  manifestation  may  give  rise  to  either  of  these  conditions.  Finally, 
diverticula  may  arise  from  traction  on  the  esophagus  from  without  from  en- 
larged lymphatic  glands  (traction  diverticula)  or  from  pressure  from  within 
(propulsion  diverticula,  Z  i  e  m  s  s  e  n). 


622  SURGERY   OF   THE    XECK 

The  accumulation  of  food  in  the  esophagus  and  its  rejection  undigested 
resuh  from  increase  of  capacit}-  of  the  pouch.  When  sufficiently  marked  to 
attract  attention,  the  whalebone  bougie  a  boule  will  establish  the  diagnosis. 

Small  diverticula  may  produce  no  inconvenience  for  a  long  time.  Their 
tendency  is  to  increase,  however,  and  inability  to  obtain  sufficient  nutriment 
may  render  starvation  imminent.  Under  these  circumstances  gastrotomy 
should  be  performed  and  the  cardiac  orifice  thoroughly  and  efficiently 
overdilated  to  overcome  the  tendency  to  spasm  (M  i  k  u  1  i  c  z).  The  opening 
in  the  stomach  wall  is  then  closed.  Exceedingly  good  results  have  followed 
this  procedure  in  the  hands  of  its  originator. 

When  symptoms  of  stricture  of  the  esophagus  arise  as  a  part  of  the  com- 
plexus  of  s3'mptoms  constituting  the  condition  known  as  hysteria  (hysteric 
dysphagia),  the  occasional  passage  of  the  bougie  for  its  moral  effect  is  usually 
sufficient  for  cure. 

The  Treatment  of  Stricture  of  the  Esophagus. — The  preventive 
treatment  of  cicatricial  stenosis,  consisting  of  the  systematic  introduc- 
tion of  an  esophageal  sound  or  bougie,  should  be  instituted  in  about  the 
third  week  after  the  accident  of  swallowing  caustic  fluids.  At  first  daily 
seances,  followed  by  weekly  and  finally  by  less  frequent  ones,  are  indicated,  as 
in  urethral  stricture.  The  case  comes  to  the  surgeon,  however,  only  after 
difficulty  in  swallowing  is  experienced.  Small  bodies  (kernels  of  nuts,  lemon 
seeds,  etc.)  may  lodge  at  the  point  of  stricture  and  produce  ulceration,  neces- 
sitating esophagotomy. 

Gradual  dilatation  (T  r  o  u  s  s  e  a  u)  is  carried  on  by  means  of  the  bougie 
a  boule.  Gradually  increasing  sizes  are  employed  three  or  four  times  a  week 
when  the  parts  are  irritable,  and  daily  when  the  parts  are  tolerant  or  the  symp- 
toms urgent.  In  adults  sizes  from  35  to  40  (French)  may  be  reached,  after 
which  the  largest  size  possible  is  to  be  passed  occasionally  to  insure  patency 
of  the  lumen,  the  stricture  tending  to  constant  recontraction. 

In  cases  of  cicatricial  stricture  a  temporary  gastrotomy  should  be  per- 
formed and  an  effort  made  to  pass  an  instrument  from  lielow.  If  successful, 
Abbe's  bowstring  method  of  dividing  the  stricture  should  be  em- 
ployed {vide  injra).  In  case  of  failure  to  pass  the  stricture  with  the  smallest 
instrument,  a  permanent  gastric  orifice  should  be  established  for  feeding 
purposes  (see  Gastrostomy). 

External  Esophagotomy. — When  the  stricture  is  situated  in  the  cervical 
portion  of  the  esophagus  and  is  accessible  from  without,  it  may  be  divided 
from  the  latter  direction,  and  narrow  circular  strictures  may  even  be  excised 
(resection  of  the  esophagus,  Billroth).  Dilatation  must  be  subsequently 
employed  to  prevent  recontraction. 

Internal  Esophagotomy. — Strictures  of  the  thoracic  portion  not  amen- 
able to  gradual  dilatation  have  been  subjected  to  incisions  from  within, 
and  for  this  purpose  esophagotomes  (M  a  i  s  o  n  n  e  u  v  e  ,  Sands,  Mac- 
kenzie) are  employed  (Fig.  372).  Here  also  recontraction  must  be  pro- 
vided against  by  the  occasional  subsequent  introduction  of  a  dilating  instru- 
ment. In  performing  the  operation  care  must  be  taken  not  to  cut  through 
the  wall  of  the  esophagus.  The  latter  is  simply  nicked  at  one  or  more  points 
to  permit  the  introduction  of  dilating  instniments.  The  exact  status  of  the 
operation  has  not  yet  been  determined. 


THE    ESOPHAGUS  623 

Abbe's  method  of  treatment  consists  in  performing  a  gastrotomy  and  pass- 
ing one  eml  of  a  string  from  the  opening  in  the  stomach  through  the  esophagus 
and  out  of  the  mouth  by  means  of  a  gum  elastic  catheter  or  other  instrument 
that  will  pass  the  stricture.  The  string  is  then  made  tense  and  drawn  rapidly 
back  and  forth  until  the  stricture  is  divided.  The  gastrotomy  wound  is  then 
closed.  Recurrence  is  prevented  by  the  frecjuent  introduction  of  esophageal 
bougies. 

Intractable  strictures  require  the  establishment  of  an  esophageal  fistula  in 
the  cervical  region,  if  the}^  are  situated  sufficiently  high  up,  or  gastrotomy. 
In  the  former  case  the  esophagus  is  opened  low  down  in  the  neck  and  its  mucous 
membrane  sutured  to  the  skin;  or  it  ma}'  l^e  completel}'  di^•ided  and  secured  by 
suturing  into  the  external  opening  (esophagostomyj.  (For  making  an  arti- 
ficial mouth  at  the  stomach,  see  Gastrostomy.) 

In  carcinomatous  stricture  the  treatment  resolves  itself  into  operative 
methods  designed  to  prevent  the  patient  from  starving  to  death.  Further,  the 
withdrawal  of  food  from  the  natural  passage  and^the  substitution  therefor  of 
artificial  feeding  through  an  esophageal  fistula,  or  a  gastric  mouth,  will  retard 
the  progress  of  the  disease  by  remo^ang  the  irritation  arising  from  the  attempt  to 
force  food  through  the  narrowed  lumen  of  the  tube.  Attempts  at  dilatation 
are  ahsohdely  coiitra  indicated. 

The  Operation   of  External  Esophagotomy. — The  indications  for  the 


Fig.  372. — Roe's  Modification  of  Mackenzie's  Esophagotome. 

operation  have  already  been  discussed  (viz.,  foreign  bodies,  strictures,  and 
possibly  diverticula).  When  a  large  foreign  body  is  situated  high  up  in  the 
tube  and  can  be  felt  from  without,  this  may  form  a  sufficient  guide  for  the 
incision.  Or,  when  practicable  a  curved  sound  may  be  introduced  and  the 
parts  made  prominent  by  pressure  from  wdthin.  The  left  side  is  to  be  selected 
for  the  opening,  on  account  of  its  greater  accessibility.  It  is  covered  almost 
entirely  b}"  the  trachea  on  the  right  side.  When  necessary,  as,'  for  instance, 
when  a  left-sided  goiter  complicates  the  case,  the  opening  ma}"  be  made  on 
the  right  side. 

The  incision  is  made  along  the  anterior  edge  of  the  stemomastoid  muscle. 
The  platysma  myoides  and  superficial  fascia  are  divided,  and  by  retracting  the 
inner  edge  of  the  stemomastoid  outward  and  the  sternothyroid  inward,  the 
omohyoid  is  exposed.  If  necessar}^,  this  may  be  divided.  If  the  operation  is 
performed  on  a  level  with  the  larynx,  after  the  thyroid  fascia  is  divided  the  gland 
itseh  is  drawn  inward.  The  inferior  thyroid  artery,  if  necessar}'',  may  be  divided 
between  two  ligatures.  It  lies  on  the  longus  colli  at  this  point.  The  carotid 
arter}'  is  drawn  outward  with  a  blunt  retractor.  The  esophagus  and  lateral 
edge  of  the  trachea  are  now  exposed.  Care  must  be  taken  at  this  point  not  to 
injure  the  recurrent  lar}'ngeal  nerve,  which  passes  between  the  esophagus  and  the 
trachea  toward  the  outer  aspect  of  both  organs.  The  esophagus  is  recognized 
by  its  pale  red  color  and  longitudinal  muscular  fibers.  If  a  sound  has  been 
pre^^ously  introduced  as  a  guide,  the  tube  may  be  opened  upon  this.  It  is 
difficult  to  open  it  in  the  coUapsed  state.     Tliis  opening  is  to  be  made  on  its 


624  SURGERY   OF   THE   NECK 

lateral  aspect  and  should  be  large  enough  to  introduce  the  index-finger;  it  may 
be  enlarged  subsequently,  if  necessary.  If  the  operation  is  performed  for  the 
removal  of  a  foreign  body,  the  esophagus  may  be  closely  sutured  with  fine 
chromicized  catgut,  Ixit  the  remainder  of  the  wound  is  to  be  left  open  to  avoid 
infiltration,  should  tlie  esophageal  sutures  give  way.  If  for  stricture,  this  may 
be  dilated,  or,  if  this  is  intractable  or  carcinomatous,  the  mucous  membrane 
is  to  be  stitched  to  the  skin  (esophagostomy),  and  a  permanent  opening  estab- 
lished for  purposes  of  artificial  feeding. 

Resection  of  the  esophagus  (esophagectomy)  was  suggested  by  Bill- 
roth (ls7()j  after  experiments  on  animals.  Later,  Czerny  (1873)  per- 
formed the  operation  for  annular  carcinoma  in  the  cervical  portion  of  the 
esophagus  in  a  woman  of  fifty -one.  The  patient  was  able  to  take  food  through 
the  opening  left,  Ijut  died  from  local  recurrence  fifteen  months  later. 
j\I  i  k  u  1  i  c  z  has  reported  10  cases.     Rose  operated  successfully  in  1887. 

THE  LATERAL  REGION  OF  THE  NECK 

A  line  drawn  from  the  mastoid  process  to  the  inner  third  of  the  clavicle 
limits  the  area  in  this  region  within  which  punctured,  incised,  and  gunshot 
wounds  endanger  life.  Here,  passing  in  a  vertical  direction,  are  found  the 
carotid  artery,  internal  jugular  vein,  and,  more  deeply  placed,  the  vertebral 
artery  and  the  pneumogastric,  sympathetic,  and  phrenic  nerves.  Just  above 
and  partly  behind  the  clavicle  are  placed  the  subclavian  artery  and  vein,  and 
above  is  the  brachial  plexus.  It  is  a  matter  of  surprise  how  frequently  the 
vessels  in  this  region  escape  in  cases  of  punctured  and  gunshot  wounds  of  the 
neck.  This  is  due  to  the  elasticity  of  their  walls.  The  latter,  however,  may 
become  contused,  in  which  case  a  slough  occurs  and  fatal  hemorrhage  frequently 
follows.  Contour  shots  in  this  neighborhood  ai'e  not  uncommon,  a  sudden  turn 
of  the  head  at  the  moment  when  the  ball  strikes  accounting  for  these. 

In  suicidal  wounds  of  this  region  the  larynx  usually  receives  the  greatest 
inju^^^  The  weapon  may,  however,  reach  the  anterior  edge  of  the  sterno- 
mastoid  muscle  and  even  open  the  common  carotid  artery. 

Operation  wounds  occasionally  divide  the  platysma,  omohyoid,  digas- 
tric, and  stylohyoid  muscles.  These,  however,  are  not  of  special  importance; 
even  partial  or  complete  extirpation  of  the  sternomastoid  does  not  produce 
serious  functional  disturbances. 

Rupture  of  the  sternomastoid  muscle  in  the  child  during  delivery  some- 
times produces  torticollis  (wryneck  or  caput  obstipum  of  the  newborn). 

Hemothorax,  pneumothorax,  and  pyothorax  may  result  from  punctured 
wounds  afTecting  the  lower  portion  of  the  neck,  the  projecting  portion  of  the 
pleura  in  this  region  being  involved. 

Deforming  Cicatrices  of  the  Neck. — These  result  from  extensive  burns. 
While  they  may  be  sometimes  obviated  in  a  measure  b}^  means  of  early 
aseptic  treatment  and  skin  transplantation,  they  are  frequently  unavoidable. 
In  addition  to  the  cicatricial  contraction  of  the  skin  and  subcutaneous 
connective  tissue,  the  platysma  myoides  and  its  connections  are  affected, 
the  deformit}^  extending  beyond  the  parts  originally  involved  in  the  burn 
to  the  lower  lip  and  angles  of  the  mouth  (Fig.  373)  and  eye.  The  treat- 
ment consists  in  dissecting  away  the  entire  cicatricial  mass  when  practicable 


THE    LATERAL    REGION    OF    THE    NECK 


625 


and  siii)i)lyin,ii;  its  place  witii  transplanted  pediculated  flaps.  When  this  is  not 
feasililo,  tiie  cicatricial  band  is  to  be  completely  divided,  the  position  of  the  head 
corrected  to  h>'i)crextension,  and  a  flap  of  skin  with  pedicle  transplanted  to  fill 
the  defect  (B  1  a  s  i  u  s).  Or,  the  method  by  double  j)ediclc  may  be  em])loyed. 
This  consists  in  raising  the  flap  of  healthy  adjoining  skin,  leaving  it  attached  by 
both  ends,  but  loosening  it  entirely  in  the  middle  and  passing  a  strip  of  oiled 
silk  beneath  it  to  prevent  reunion  to  the  parts  beneath.  When  a  granulating 
surface  has  been  secured  on  the  raw  surface  of  the  flap,  this  is  severed  at  one  end, 
deprived  of  its  granulating  surface  by  paring,  and  the  gap  left  by  the  division 
of  the  cicatrix  and  reduction  of  the  deformity  filled  with  the  flap  (Croft). 
Fixation  apparatus  is  to  be  ap- 
plied to  keep  the  parts  at  rest 
and  maintain  the  head  in  posi- 
tion. 

Injuries  of  Cervical 
Nerves. — Injuries  of  the  cer- 
vical sympathetic  nerves  may 
result  in  paralysis  of  the  vaso- 
motor supply,  as  shown  by  flush- 
ing, or  a  red  blush  on  the  cor- 
responding side  of  the  face  (see 
Cervical  Sympathectomy) . 

The  pneumogastric  nerve 
may  be  injured  by  operations 
about  the  neck.  Death  usually 
follow^s  within  a  few  days,  though 
recoveries  after  this  accident 
have  been  reported.  In  one  case 
excision  of  a  portion  of  the  pneu- 
mogastric nerve  in  a  patient  was 
not  followed  by  serious  disturb- 
ances, other  than  paralysis  of 
one  vocal  cord  (Billroth). 
Interference  with  respiration, 
however,  is  the  rule. 

Injury  of  the  phrenic  nerve  results  in  paralysis  of  half  of  the  diaphragm, 
and  life  is  endangered,  in  spite  of  the  fact  that  the  other  half  of  the  diaphragm 
and  the  other  respiratory  muscles  continue  to  act. 

The  spinal  accessory  nerve  may  be  injured  during  operations  for  the 
removal  of  tumors  lying  between  the  external  edge  of  the  sternomastoid  and 
the  anterior  edge  of  the  trapezius.  The  function  of  the  sternomastoid  is  not 
greatly  interfered  with,  and  the  levator  anguli  scapulae  supplies  to  some  extent 
the  place  of  the  trapezius. 

Division  of  individual  branches  of  the  cervical  plexus  is  not  followed  by 
serious  results  on  account  of  their  free  communication  with  branches  of  the 
fifth  cranial  nerve  above  and  the  brachial  plexus  below. 

Injuries  of  the  recurrent  laryngeal  nerve  have  been  discussed  in  connection 
with  excision  of  goiter. 

The  hypoglossal  nerve  may  be  injured  during  operations  about  the  angle 
41 


Fig.    373. 


-Contraction    of   Cicatrix   and    Platysma 
Myoides  Following  Burns. 
The  lower  lip  and  angles  of  the  mouth  are  practically  ob- 
Uterated.      Dr.  Everson's  case 


626  SURGERY   OF   THE    XECK 

of  the  jaw,  the  injury  resulting  in  paralysis  of  one  half  of  the  tongue.  Upon 
projecting  this  organ  it  is  found  to  point  toward  the  uninjured  side,  this  para- 
doxic symptom  being  due  to  the  action  of  the  geniohyoglossus  muscle,  the 
radiating  fan-like  fibers  of  which,  shortening  onl}^  on  one  side,  cause  the  healthy 
side  of  the  tongue  to  approach  the  point  of  insertion  of  the  muscle  in  the 
middle  of  the  jaw. 

The  symptoms  of  injury  of  the  brachial  ])lexus  in  the  neck  will  var\^  accord- 
ing to  whether  the  roots  of  the  median,  radial,  or  ulnar  nerves  are  involved. 

The  Treatment  of  Intractable  Facial  Paralysis  by  Nerve  Anas= 
tomosis. — Experimental  ol^servations  and  operations  in  man  have  sho^^^l 
that  cortical  impulses  may  be  made  to  reach  a  group  of  muscles  from  which 
the  normal  neural  connections  have  been  cut  off.  Even  in  the  case  of 
mixed  nerves  both  motor  and  sensoiy  functions  have  been  restored.  Well 
authenticated  instances  are  not  wanting  in  which  an  anastomosis  between  a 
paralyzed  nerve  and  a  neighboring  healthy  nerve  has  resulted  in  a  cure  of  the 
paralysis.  The  distressing  conditions  present  in  facial  pa  ralysis  may  be  remedied 
in  some  instances  by  establishing  an  anastomosis  between  the  peripheral  por- 
tion of  the  seventh  nerve  and  either  the  spinal  accessor}-  neiwe,  the  hypoglossal 
ner\' e,  or  a  motor  branch  from  the  cer^dcal  plexus.  In  case  the  spinal  accessory 
is  selected  for  the  purpose,  emotional  movements  of  the  face  are  accompanied 
by  disfiguring  movements  of  the  shoulder  (Gushing). 

The  operation  is  usually  indicated  in  paralysis  secondarv'  to  middle-ear 
disease,  operations,  injuries,  and  fractures  of  the  base  of  the  skull.  In  cases 
of  stab  wounds  in  which  the  nerve  is  known  to  be  cut  across,  and  in  which  pri- 
mary suture  is  impossible,  the  operation  should  be  performed  at  once.  In  other 
cases  electric  treatment  and  massage  should  l^e  persevered  in  for  at  least  six 
months,  at  the  end  of  which  time,  provided  the  presence  of  muscular  fibers  on 
the  paralyzed  side  of  the  face  can  be  demonstrated  by  electricity,  the  operation 
should  be  performed. 

The  operation  of  choice  consists  in  implantation  of  the  facial  on  the  hypo- 
glossal ner\-e  (facio-hypoglossal  anastomosis,  B  a  1 1  a  n  c  e  and  Stewart). 
The  hj-poglO'Ssal  ner\'e  is  exposed  above  the  posterior  belly  of  the  digastric. 
The  incision  is  planned  so  as  to  include  the  peripheral  portion  of  the  seventh 
nerve,  and  the  twelfth  nerve  at  the  point  mentioned.  The  facial  nerve  is  most 
easily  exposed  by  incising  the  posterior  border  of  the  parotid  gland  (Gush- 
ing). The  hypoglossal  should  be  very  carefuUy  manipulated  during  the  oper- 
ation, lest  paralysis  of  one  side  of  the  tongue  foUow;  the  least  possible  amount 
of  suture  material  should  be  used.  Only  the  nerv'e-sheath  should  be  included 
in  the  sutures.  Noticeable  improvement  may  be  expected  at  the  end  of  three 
months.     This  should  be  assisted  by  electricity  and  massage. 

Injuries  of  the  Vessels. — In  punctured,  incised,  and  gunshot  injuries 
of  the  large  arteries  of  the  neck  and  their-  branches  (iimominate,  subclavian, 
and  common  carotid)  the  hemorrhage  usually  proves  fatal  before  the 
arrival  of  surgical  help.  In  provisional  arrest  of  hemorrhage  from  the 
carotid  the  tnmk  of  this  vessel  may  be  pressed  with  the  finger  against  the 
transverse  process  of  the  sixth  cervical  vertebra  (Ghassaignac's  carotid 
tubercle).  Bleeding  from  the  collateral  current  is  to  be  arrested  by  pressure 
either  immecUately  above  the  wound  or  in  the  wound  itself.  The  subclavian 
may  be  pressed  from  behind  the  clavicle  against  the  first  rib  in  lean  individuals 


THE    LATERAL   REGION    OF   THE    NECK  627 

after  depressino;  the  shoulder;  in  stout  persons  and  when  the  shoulder  cannot 
be  sufficiently  depressed,  this  may  fail.  The  hemorrhage  may  then  be  arrested 
by  making  pressure  from  before  backward  so  as  to  compress  the  artery  against 
the  middle  scalenus  muscle  and  the  transverse  process  of  the  seventh  cervical 
vertebra.  This  failing,  the  method  of  strongly  adducting  the  arm  and  placing 
the  elbow  in  the  epigastrium  and  the  hand  on  the  opposite  shoulder  may  be 
tried.  By  this  maneuver  the  cla\'icle  is  brought  firmly  down  on  the  first  rib 
and  the  vessel  compressed  between  the  two  l^ones.  Finally,  direct  pressure 
may  be  made  upon  the  artery  by  the  finger  through  an  incision  made  in  the 
cervical  fascia.  If  hemorrhage  persists  from  a  wound  of  the  carotid  after 
the  latter  is  firmly  compressed  against  Chassaignac's  tubercle,  the 
bleeding  comes  through  the  vertebrals,  which  cannot  be  compressed  by  manual 
pressure. 

With  temporary  arrest  of  the  bleeding  the  patient's  head  is, to  be  lowered, 
if  he  feels  faint  or  the  pulse  is  greatly  weakened,  and  bandages  applied  to  the 
extremities  to  force  the  blood  into  the  trunk  and  head  (autotransfusion).  When 
the  patient  rallies,  the  wound  is  to  be  explored  and  both  ends  of  the  vessel 
secured  by  ligature.  If  this  is  found  to  be  impossible,  ligation  in  continuity  is 
to  be  resorted  to. 

After  the  permanent  arrest  of  the  hemorrhage,  should  the  patient's  life  be 
threatened  from  acute  anemia,  infusion  of  salt  solution  should  be  employed 
(see  page  351). 

Incised  wounds  of  large  venous  trunks,  particularly  of  the  innominate  and 
internal  jugular  veins,  are  almost  invariably  fatal,  both  from  loss  of  blood  and 
from  entrance  of  air.  In  gunshot  and  punctured  wounds  gaping  is  not  so  great, 
at  least  in  case  of  the  jugular  vein,  and  compression  may  be  effected  by  placing 
the  finger  directly  in  the  wound  until  a  graduated  compress  can  be  applied.  If 
the  hemorrhage  recurs,  the  parts  must  be  explored  and  the  vein  ligated  both 
above  and  below  the  wound.  If  the  wound  of  the  vein  is  small  and  involves  only 
one  wall,  lateral  ligation  is  indicated.  Of  the  superficial  veins,  the  external 
jugular  is  most  easily  injured,  particularly  in  operations  in  this  region.  To 
avoid  entrance  of  air  it  should  be  ligated  before  division.  If  not  easily  discern- 
ible, it  may  be  brought  out  prominently  by  pressure  immediately  above  the 
clavicle. 

Inflammations  in  the  Lateral  Cervical  Region. — Inflammatory  con- 
ditions m  the  cervical  region  spread  easily  on  account  of  the  loose  layers  of 
cellular  tissue  which  connect  the  muscular  tissue  and  organs  in  this  locality. 

Abscesses  may  arise  from  different  neighboring  organs,  such  as  the  parotid 
gland,  the  submaxillary  gland,  and  the  cervical  vertebrae  (migrating  ab- 
scesses) .  Those  arising  from  the  glandular  structures  are  more  superficial  and 
may  be  opened  early,  so  that  diffuse  phlegmon  of  the  neck  is  prevented. 
Those  arising  from  the  cervical  vertebrae  are  more  deeply  placed,  and  are  scarcely 
recognized  until  they  appear  at  certain  points. 

Lymphadenitis  of  the  lateral  cervical  region  is  a  very  common  affection. 
The  affection  may.  be  divided  into  that  having  a  tuberculous  origin  with  cheesy 
infiltration,  and  the  true  inflammatory  variety  arising  from  septic  infection  and 
proceeding  rapidly  to  supiDuration.  In  both  varieties  the  immediate  source  of 
infection  is  the  lymph-cun-ent. 

Tuberculous  lymphadenitis  is  characterized  by  its  chronic  course  and  by 


628  SURGERY   OF   THE    NECK 

the  fact  that  several  neighboring  ghmcls  are  simiiltaneou.sly  attacked.  The 
affection  is  not  infrequently  bilateral.  Either  the  swollen  structure  of  the 
gland  becomes  tlie  seat  of  a  slowly  developed  cheesy  infiltration,  or  suppurative 
changes  occur  in  it,  the  capsule  being  perforated  and  the  connective  tissue 
surrounding  the  gland  becoming  involved  (paradenitis).  Even  under  these 
circumstances  the  course  of  the  affection  is  slow  and  rarely  ends  in  destruction 
of  the  entire  gland.  The  entire  organism  may  be  endangered  by  tuberculous 
infection,  either  from  the  cheesy  glandular  infiltration,  or  from  the  bacilli 
present  in  the  fistulous  tracks  which  lead  to  broken-down  foci  within  the  glands. 
Should  a  fair  trial  of  intraparenchymatous  injections  of  iodin  fail  (see  page  112), 
early  and  radical  extirpation  of  diseased  glands,  particularly  when  these  have 
become  the  seat  of  cheesy  metamorphosis,  or  of  suppurative  changes,  is 
indicated. 

Septic  Lymphadenitis. — The  infection  originates  in  the  buccal  or  pharyn- 
geal ca^■ity,  and  attacks,  as  a  rule,  but  a  single  gland.  The  inflammation 
usually  pursues  an  acute  course,  ending  either  in  early  resolution  or  in  suppura- 
tion. In  the  latter  case  the  capsule  is  perforated  and  suppurative  paradenitis 
or  even  phlegmonous  inflammation  of  the  neck  ensues.  When  arising  from 
glands  just  beneath  the  superficial  fascia,  this  form  is  comparatively  harmless; 
it  points  early  and  is  easily  managed  by  incision.  When  originating  from  glands 
more  deeply  situated  or  extending  to  the  area  of  the  middle  cervical  fascia 
through  the  medium  of  the  perforating  lymph-channels  of  L  u  d  w  i  g  (Lud- 
wig's  angina),  the  suppurative  process  may  follow  the  sternothyroid  muscle 
to  the  space  between  the  anterior  surface  of  the  trachea  and  the  depressors  of 
the  hyoid  bone  (the  pre  visceral  space  of  Henle),  or  along  the  inner  surface  of 
the  sternomastoid,  or  the  perivascular  connective  tissue  of  the  large  vessels, 
to  the  anterior  mediastinum  (suppurative  mediastinitis).  Under  these 
circumstances  the  affection  is  accompanied  by  high  fever  and  other  alarming 
symptoms  of  a  septic  character,  and  sometimes  passes  entirely  beyond  surgical 
control.  If  the  area  of  the  deep  cervical  fascia  is  invaded,  it  may  reach  the 
retrovisceral  space  between  the  esophagus  and  the  vertebral  column,  in  which 
case  a  fatal  result  almost  invariably  follows.  In  addition  to  high  fever  and 
marked  pain,  difficulty  in  swallowing  is  complained  of.  Therefore,  in  the 
treatment  of  septic  lymphadenitis,  the  more  deeply  phlegmonous  par- 
adenitis penetrates,  the  more  urgent  the  necessity  for  early  interference.  The 
suppurating  focus  should  be  exposed  by  careful  and  formal  dissection,  as  for  the 
removal  of  a  deep  tumor  from  this  region,  injury  of  the  vessels  being  avoided 
by  separating  natural  lines  of  cleavage  by  means  of  the  blades  of  anatomic  or 
hemostatic  forceps.  The  search  must  be  persisted  in  until  the  source  of  the 
.suppuration  is  reached. 

Congenital  Hydrocele  and  Other  Cystic  Tumors  of  the  Neck.— Con- 
genital hydrocele  of  the  neck  is  a  cystic  formation  found  most  frequently  be- 
tween the  hyoid  bone  and  the  mastoid  process,  and  also  in  the  region  of  the 
external  carotid  artery  and  supraclavicular  fossa.  The  tumor  increases 
gradually  in  size  and  is  the  result  of  accumulation  of  secretion  from  its  walls, 
lined  with  layers  of  pavement  or  of  ciliated  epithelium.  These  walls  represent 
unobliterated  portions  of  the  branchial  clefts  (branchial  cysts).  They  may 
extend  to  the  styloid  process,  to  the  hyoid  bone,  to  the  anterior  pharyngeal  wall, 
or  even  to  the  anterior  mediastinum.     The  contents  of  these  cysts  may  be  light- 


THE  LATERAL  REGION  OF  THE  NECK  629 

colored  and  serous,  or  inucuslila',  eontainiii.i;-  crystals  of  cholesterin.  The 
atheromatous  cysts  soin(>1iin(»s  found  in  immediate  connection  with  the  sheath 
of  the  carotid  artery  j)rol)al)ly  belong  to  the  same  class.  These  may  also 
contain  cartilage  (auricular  teratomas  of  V  i  r  c  h  o  w). 

Treatment. — A  certain  degree  of  success  follows  the  method  of  emptying 
the  cyst  and  injecting  tincture  of  iodin  or  Lugol's  solution.  The  injections 
may  be  repeated  several  times,  if  necessary  (Es  march).  Incision  and 
drainage  may  also  be  employed  {B  a  r  d  e  1  e  b  e  n).  Extirpation  of  the  sac, 
however,  is  the  most  trustworthy  method  of  cure,  though  the  operation  is 
difficult  and  not  unattended  with  danger. 

Congenital  fistula  of  the  neck  results  from  failure  of  closure  of  a 
branchial  cleft  (branchial  fistula).  This  may  be  bilateral  (18  out  of  82  cases, 
according  to  G  .  F  i  s  c  h  e  r) .  It  may  be  hereditary.  The  fistula  is  usually 
situated  at  the  lower  third  of  the  anterior  edge  of  the  sternomastoicl  muscle, 
near  the  sternoclavicular  articulation.  It  usually  takes  a  direction  upward  and 
toward  the  median  line  and  sometimes  communicates  with  the  pharyngeal 
cavity.  The  inner  wall  of  the  fistula  is  lined  with  ciliated  epithelium  (R  o  t  h). 
These  fistulas  have  been  successfully  treated  by  injections  of  tincture  of  iodin 
(Rehn  and  Serres).  The  galvanocautery  has  been  recommended 
(G  .  Fischer).  Excision  of  the  fistulous  track  has  been  successfully  per- 
formed (H  u  e  t  e  r). 

Median  congenital  fistula  of  the  neck  (tracheal  fistula)  has  been  ob- 
served. Though  this  is  said  to  occur  only  in  women  (B  a  r  d  e  1  e  b  e  n),  I  have 
seen  it  in  both  sexes.  The  fistula  passes  directly  backward  to  the  trachea, 
without  invading  it,  however. 

Branchiogenous  carcinoma,  or  carcinoma  having  its  origin  in  the 
epithehal  structure  of  unobliterated  branchial  clefts,  has  been  observed  (V  o  1  k  - 
m  a  n  n  ,   P.   B  r  u  n  s). 

Congenital  Cystic  Hygroma. — This  is  a  multilocular  cystic  formation 
which  sometimes  originates  in  the  submaxillary  region.  It  may  extend  over 
the  entire  lateral  and  anterior  region  of  the  neck.  The  surface  of  the  tumor  is 
lobulated,  the  lobes  corresponding  to  the  indi\adual  cysts.  The  contents  are 
serous  and  yellowish  in  color  or  brownish  from  admixture  with  decomposed 
blood.  The  inner  wall  is  lined  with  a  layer  analogous  to  the  epithelium  of 
lymph-vessels,  and  the  cyst  cavities  can  sometimes  be  demonstrated  as  com- 
municating with  the  lymph-spaces  of  lymphatic  glands  (W  i  n  i  w  a  r  t  e  r  , 
Wagner  and  others).  H  u  e  t  e  r  proposed  the  name  congenital  l5rmph- 
angiectasis,  and  Wagner  congenital  lymphangioma.  The  growth  some- 
times forces  its  way  through  the  intramuscular  spaces  until  it  reaches  the 
vertebral  column.     Its  presence  may  cause  interference  with  respiration. 

Treatment. — Temporary  relief  may  be  obtained  by  puncturing  several  of 
the  cysts  and  emptying  them  of  their  contents.  Injections  of  tincture  of  iodin 
are  contraindicated  because  of  the  ramifications  of  the  growth  and  the  probable 
occurrence  of  deep-seated  and  perhaps  violent  inflammation.  Isolated  and 
superficial  cj'sts  ma}^  be  extirpated. 

Blood  cysts,  apparent^  arising  as  a  congenital  formation,  may  develop 
later  in  life.  They  communicate  with  one  or  more  veins  of  the  lateral  region 
of  the  neck.  H  u  e  t  e  r  extirpated  one  of  these  tumors,  which  proved  to  corre- 
spond in  situation  to  the  internal  jugular  vein.     These  C3"sts  contain  partly  liquid 


630  SURGERY   OF   THE   NECK 

and  i)artly  coagulated  l)lo()d.  The  walls  are  sometimes  covered  with  blood- 
clot  in  process  of  organization.  In  the  treatment  of  these  cysts  injections  of 
tincture  of  iodin  arc  contraindicated  on  account  of  the  danger  of  their  entering 
the  veins  and  reaching  the  right  heart.  In  extirpating  the  tumor  care  must 
be  taken  not  to  injure  the  cyst  wall,  as  hemorrhage  from  the  communicating 
veins  may  be  dangerous. 

Echinococci  of  the  lateral  region  of  the  neck  are  rare.  Two  cases  suc- 
cessfully operated  on  are  recorded  (Hueter).  Cystic  goiter  has  been 
already  discussed  (see  page  611).  Noncongenital  hydrocele  of  the  neck 
(]\I  a  d  e  1  u  n  g)  probably  arises  as  a  cyst  of  the  thyroid  isthmus  or  of  the  third 
lobe,  sometimes  called  the  pyramid. 

Hydrops  of  the  Thyrohyoid  Bursa. — This  is  a  dropsy  of  the  bursa  which 
exists  between  the  lavers  of  the  thyrohyoid  membrane  in  the  space  where  these 
are  separated  from  each  other.  A  flattened  and  fluctuating  tumor  may  develop 
from  accumulation  of  the  secretion  of  the  bursa,  probably  induced  by  infection. 
The  skin  becomes  thickened  and  reddened  and  the  adjoining  connective  tissue 
is  infiltrated,  resembling  L  u  d  w  i  g  '  s  angina.  The  center  of  the  latter,  how- 
ever, always  lies  near  the  angle  of  the  jaw.  The  treatment  consists  in  free 
incision  and  subsec^uent  open  dressing  of  the  wound,  the  latter  being  allowed  to 
heal  by  granulation. 

TUMORS  OF  THE  SKIN,  MUSCLES,  AND  VESSELS  OF  THE  NECK 

Angiomas,  nevi  pigmentosi,  atheromas,  lipomas,  papillomas,  and 
fibromas  occur  occasionally  in  the  skin  of  the  neck. 

Neoplasms  of  the  cervical  muscles  are  rarely  observed.  The  fusiform  swell- 
ing of  the  sternomastoid,  occurring  at  delivery  and  followed  by  wryneck  (see 
page  650),  is  sometimes  mistaken  for  a  tumor.  Sarcoma  having  its  origin  in 
the  connective  tissue  of  the  sheath  of  the  muscles  is  rare  in  the  lateral  cervical 
region,  as  compared  with  its  occurrence  in  the  posterior  cervical  and  scapular 
regions.     Syphilitic  gummas  of  the  sternomastoid  have  been  observed. 

Aneurism  of  the  large  vessels  in  the  lateral  cervical  region  is  not  infre- 
quent. The  disease  attacks  the  vessels  most  frequently  (1)  at  the  bifurcation 
of  the  common  carotid  into  the  external  and  internal  carotid;  (2)  at  the 
division  of  the  innominate  artery  into  the  right  subclavian  and  right  common 
carotid.  Other  portions  of  the  vessels  may  also  be  attacked,  though  less 
frec^uently.  The  presence  of  a  cervical  rib  (an  abnormal  lengthening  of  the 
transverse  process  of  the  seventh  cervical  vertebra)  is  said  to  be  an  occasional 
cause  of  subclavian  aneurism  at  the  point  where  the  vessel  passes  over  the 
process  (G.Fischer). 

The  diagnosis  of  aneurism  is  based  on  the  symptoms  already  described 
(see  page  97).  The  bruit  can  be  made  out  in  the  pulsating  tumor  by  both 
auscultation  and  palpation.  Aneurism  of  the  vertebral  artery  may  be  mis- 
taken for  that  of  the  common  carotid.  Compression  of  the  latter  against  the 
transverse  process  of  the  sixth  cervical  vertebra  will  aid  in  the  differentiation. 
The  carotid  artery  has  been  erroneously  ligated  for  vertebral  aneurism 
(G.Fischer). 

In  the  treatment  of  aneurism  of  the  lateral  cervical  region  reliance  must 
be  placed  on  ligation  in  continuity,  for  only  by  means  of  this  operative  pro- 
cedure can  a  cure  be  hoped  for. 


THE    LATERAL  REGION    OF   THE   NECK  631 

The  rare  occurrence  of  a  communication  between  the  common  carotid  artery 
and  the  internal  jii^i^ilar  vein  is  to  be  here  noted. 

Tumors  of  Lymphatic  Origin. — Simple  chronic  as  well  as  tuberculous 
l5rmphadenitis  gives  rise  to  intlammatory  enlargement  of  the  lymphatic 
glands  of  the  neck,  the  latter  attaining  the  size  of  the  fist  or  becoming 
even  larger.  The  superficial  cervical  glands  may  be  affected,  viz.,  (1)  the 
submaxillary,  situated  beneath  the  body  of  the  lower  jaw  in  the  sub- 
maxillar>'  triangle  and  closely  adherent  to  the  submaxillary  salivary  gland;  (2) 
the  suprahyoid,  situated  in  the  middle  line  of  the  neck  on  the  mylohyoid 
muscle  and  between  the  anterior  bellies  of  the  two  digastric  muscles;  (3)  the 
lateral  cervical,  placed  in  the  course  of  the  external  jugular  vein  between  the 
platysma  and  the  deep  fascia  Involvement  of  the  deep  cervical  glands  in- 
cludes (1)  the  chain  beneath  the  sternomastoid  and  on  its  anterior  edge,  and 
intimately  attached  to  the  sheath  of  the  carotid  artery  and  the  internal  jugular 
vein  above  the  bifurcation  of  the  former,  the  upper  deep  cervical  or  supra- 
carotid  glands;  (2)  the  lower  deep  cervical  glands,  clustered  around  the 
lower  part  of  the  internal  jugular  vein  and  extending  to  the  supraclavicular 
fossa;  (3)  the  supraclavicular  group.  The  latter  is  continuous  externally 
with  the  axillary  and  internally  with  the  mediastinal  glands.  In  addition  to 
these,  the  occipital  glands,  which  lie  between  the  superior  posterior  edge  of  the 
sternomastoid  and  the  trapezius,  and  the  posterior  auricular  group  may  be 
involved.  Finally,  a  prevertebral  group,  situated  at  the  anterior  surface  of  the 
cervical  vertebrae,  and  an  internal  carotid  group,  extending  along  the  internal 
carotid  artery  to  the  base  of  the  skull,  may  be  included  in  the  classification, 
though  these  are  usually  inaccessible  operatively. 

These  same  glandular  groups  may  be  the  seat  of  infection  from  primary 
carcinoma  with  resulting  secondary  carcinomatous  infiltration,  or  simple 
inflammatory  enlargement  may  result  from  the  ulcerative  changes  occurring  in 
malignant  disease  within  the  area  of  communication  of  the  respective  groups. 
It  is  best,  however,  not  to  trust  to  the  latter  possibility,  but  to  regard  all 
glandular  enlargements  in  the  neighborhood  of  cancerous  disease  as  being 
essentially  malignant  in  character. 

The  following  table  shows  the  relation  of  the  respective  groups  of  glands  to 
the  periphery  (Treves): 

Region. 

(  Posterior  part.  Suboccipital  and  mastoid  (posterior  auricular)  glands. 

Scalp         \  Frontal  and    parie-  Parotid  lymphatic  glands ;  superficial  cervical  glands. 

(      tal  portions. 

Bkin  of  face  and  neck.  Submaxillary,  parotid,  and  superficial  cervical  glands. 

External  ear.  Superficial  cervical  glands. 

Lower  lip.  Submaxillary  and  superficial  cervical  glands. 

Buccal  cavity.  Submaxillary  and  upper  set  of  deep  cervical  glands. 

~  ■Gums  of  loiver  jaw.  Submaxillary  glands. 

rp  J  Anterior  portion.  Suprahyoid  and  submaxillary  glands. 

1  ongue       ^  Posterior  portion.  Upper  set  of  deep  cervical  glands. 

Tonsils  and  palate.  Upper  set  of  deep  cervical  glands. 

p.  (  Upper  part  Parotid  and  retropharyngeal  glands.. 

Pharynx    |  Lower  part.  Upper  set  of  deep  cervical  glands. 

Larynx,  orbit,  and  roof  of  mouth.  Upper  set  of  deep  cervical  glands. 

,-  Retropharyngeal    glands ;    upper  set  of    deep  cervical 

AT       7  f  '  glands. 

J\  asal  fossa.  -.  g^j^g  lymphatic  vessels  from  the  posterior  part  of  the 

(,  fossa  enter  the  parotid  lymphatic  glands. 


632  SURGERY   OF   THE   NECK 

True  lymphomas  form  a  part  of  the  disease  known  as  leukemia  (lymphatic 
leukemia),  an  affection  belonging  to  the  domain  of  internal  medicine.  The 
disease  is  characterized  b>'  the  }:)resence  of  tumors  varying  in  size  and  occur- 
ring simultaneously  in  the  cervical,  axillary,  and  inguinal  regions.  These  tumors 
differ  from  the  enlarged  glands  resulting  from  tuberculous  infection  by  being 
softer;  the  separate  glands  in  lymphatic  leukemia  may  also  be  isolated, 
whereas,  in  tuberculous  lymphadenitis,  the  glands  are  massed  together  by 
inflammatory  condensation  and  infiltration  of  the  periglandular  connective 
tissue.  i\licroscopic  examination  of  the  blood  will  assist  in  the  diagnosis, 
though  the  proportion  of  white  blood-corpuscles  is  sometimes  increased  in 
general  tuberculous  lymphadenitis. 

Sarcoma  of  the  cervical  glands  is  almost  without  exception  a  primary 
manifestation.  These  growths  occur  particularly  in  the  upper  deep  cervical 
group,  attain  a  large  size,  and  destroy  life  either  by  compression  of  the 
trachea  or  by  paralysis  of  the  pneumogastric  nerve.  The  large  vessels  of  the 
neck  are  greatly  distorted.  Sarcoma  may  also  occur  in  this  region,  having  its 
origin  in  the  connective  tissue  surrounchng  the  vessels  and  muscles.  Extirpa- 
tion, unless  attempted  early  in  the  case,  is  usually  impracticable.  Therefore 
treatment  by  means  of  injections  of  sterilized  cultures  of  the  Strepto- 
coccus erysipelatis  and  the  Bacillus  prodigiosus  (B  r  u  n  s  ,  C  o  1  e  y)  is 
to  be  attempted  (see  page  226). 

Ligation  of  tlie  Common  Carotid  Artery. — Indications. — (1)  Hemor- 
rhage; (2)  aneurism;  (3)  operation  on  tumors;  (4)  neuralgia  of  the  trigeminus 
(G  .  Fischer);  (5)  aneurism  of  the  innominate  artery  (Bras  dor's  oper- 
ation). In  cases  of  hemorrhage  the  ligation  may  be  either  preventive  or  cura- 
tive. In  operative  attacks  on  tumors  the  ligation  may  be  either  temporary  and 
provisional  or  permanent.  It  has  been  suggested  to  ligate  the  common  carotid 
artery  in  neuralgia  of  the  trigeminus  with  the  hope  of  benefiting  the  disease 
through  the  central  nutritive  changes  that  follow. 

The  mortality  following  the  operation  varies  with  the  conditions  present. 
When  the  vessel  itself  is  healthy  and  no  serious  affection  is  present,  as,  for  in- 
stance, when  the  operation  is  performed  for  neuralgia  of  the  fifth  nerve,  the 
mortality  amounts  to  5  per  cent.  The  mortality  of  all  cases  of  ligation  of  the 
vessel  is  about  40  per  cent.  Both  common  carotids  have  been  ligated  success- 
ively (32  cases).  In  one  case  an  interval  of  five  years  elapsed  between  the 
operations.  In  this  case  the  patient  lived  forty-six  years,  and  at  the  post- 
mortem it  was  found  that  the  collateral  circulation  was  carried  on  more  by  the 
ascending  cervicals  than  by  the  vertebrals  (Roth).  The  most  successful 
eases  are  those  in  which  several  weeks  intervened  between  the  operations.  In 
one  instance,  both  carotids  were  ligated  simultaneously  (Valentine 
M  o  1 1).     The  attempt  proved  unsuccessful. 

Functional  disturbances  are  present,  as  a  rule,  even  in  one-sided  ligation, 
when  the  collateral  circulation  is  established  and  recovery  takes  place.  These 
include  mental  impairment  and  paralysis  of  the  peripheral  nerve  distribu- 
tion. In  fatal  cases  due  directly  to  the  ligation  foci  of  cerebral  softening  are 
found.     In  double  ligation  these  disturbances  are  most  marked. 

The  Operation. — The  point  of  election  is  at  the  level  of  the  cricoid  cartilage 
and  above  the  omohyoid  muscle.  Below  this,  the  vessel  is  comparatively 
inaccessible,  and   above  it,  the  bifurcation  is  encroached  upon.     The  patient. 


THE  LATERAL  REGION  OF  THE  NECK 


633 


is  placed  on  his  back,  the  shoulders  supported  on  a  hard  pillow,  the  chin  drawn 
up,  and  the  head  turned  slightly  toward  the  opposite  side  (Fig.  374).     The 


Fig.  374. — "Dissecting  Room  Position"  for  Opebations  on  the  Neck. 


position  of  the  cricoid  cartilage  is  ascertained  and  a  three-inch  incision  made  in 
the  line  of  the  artery  with  the  center  on  a  level  with  the  cartilage.     The  skin 


Fig.  375. — 1,  Ligation  of  the  Common  Carotid  Artery  above  Omohyoid;  2,  Ligation  of  Subclavian 

Artery. 

and  platysma  are  incised,  the  deep  fascia  divided  along  the  anterior  edge  of  the 
sternomastoid,  and  the  latter  followed  until  the  omohyoid  muscle  is  made  out. 


634 


SURGERY   OF   THE    NECK 


The  superior  border  of  the  omohyoid  muscle  is  then  well  exposed  and  identi- 
fied. The  sternomastoid  is  retracted  outward  and  the  omohyoid  downward  (Fig. 
375).  The  carotiel  tubercle  is  now  sought  for  and  the  vessel  detected  by  its  pulsa- 
tion. The  sheath  of  the  vessel  is  opened  on  the  side  toward  the  median  hne, 
the  descendens  noni  nerve  avoided,  and  the  vessel  cleared  from  the  sheath  on  the 
inner  side  first,  the  edge  of  the  incision  in  the  sheath  being  steadied  with  strong 
forceps.  The  outer  side  is  then  freed.  For  releasing  the  artery  from  the  sheath 
a  curved  blunt  instrument,  such  as  an  unthreaded  aneurism  needle,  is  to  be  em- 
ployed. It  is  important  that  the  process  of  clearing  the  artery  from  the  sheath 
should  be  carried  out  with  great  care  and  that  it  should  be  thoroughly  done. 
The  ligature  should  be  passed  from  without  inward.     The  descendens  noni 


Fig.  376. — 1,  Ligation  of  the  Internal  and  External  Carotid;  2,  Ligation  of  the  Common  Carotid 

below  the  omohyoid;   3,  ligation  of  the  innominate. 

The  sternomastoid  is  here  shown  divided.     This  is  not  always  necessary,  but  if  ready  access  is  not  obtained, 

both  this  and  the  sternothyroid  and  sternohyoid  may  be  cut. 


nerve  and  the  pneumogastric  have  been  accidentally  included  in  the  ligature, 
and  the  artery  has  been  transfixed  by  clumsy  manipulation. 

Ligation  of  the  External  and  Internal  Carotid  Arteries.— Ligation  of 
the  external  carotid  artery  for  aneurism  is  less  frequently  indicated  than 
ligation  of  the  common  carotid.  Hemorrhage  from  the  branches  of  this  vessel 
can  be  generally  controlled  by  ligation  at  the  point  of  injury.  Bleeding  from 
the  internal  maxillary  and  its  branches  may,  however,  indicate  ligation  in 
continuity  of  the  external  carotid.  The  collateral  circulation  is  very  quickly  re- 
established by  the  free  communication  of  its  branches  (facial,  lingual,  superior 
thyroid,  and  occipital)  with  the  corresponding  arteries  of  the  opposite  side,  as 
well  as  with  branches  of   the  internal  carotid,  particularly  the  ophthalmic 


THE   LATERAL   REGION    OF   THE   NECK  635 

Ligation  of  the  external  carotid  is  most  frequently  performed  in  the  course  of 
operations  for  the  removal  of  deeply  placed  tumors. 

I  haye  found  preliminary  ligation  of  the  vessel  beyond  the  facial  and  occip- 
ital branches  of  ath'antage  in  controlling  the  hemorrhage  from  the  middle 
meningeal  branch  in  intracranial  neurectomy  of  the  trigeminus  in  intractable 
neuralgia  (see  page  541). 

Operation. — A  line  drawn  from  the  external  auditory  meatus  to  the  side  of 
the  cricoid  cartilage  marks  the  line  of  the  artery  with  sufficient  accuracy.  An 
incision  two  and  a  half  inches  in  length  is  made  on  this  line,  with  its  center 
resting  on  the  greater  cornu  of  the  hyoid  bone.  The  vessel  is  reached  by  baring 
the  anterior  edge  of  the  sternomastoid  muscle,  retracting  the  latter  outward, 
identifying  the  greater  cornu  of  the  hyoid  bone,  and  after  the  posterior  belly  of 
the  digastric  at  the  upper  angle  of  the  wound  and  the  hypoglossal  nerve  at  the 
lower  angle  are  located,  by  exposing  the  artery  between  the  origins  of  its 
superior  thyroid  and  lingual  branches.  After  the  artery  is  cleared  the  aneurism 
needle  is  passed  from  within  outw^ard,  care  being  taken  to  avoid  the  superior 
laryngeal  nerve,  which  curves  behind  the  artery  at  this  point.  In  order  to 
minimize  the  risks  of  secondary  hemorrhage  it  has  been  advised  to  secure  the 
superior  thyroid,  lingual,  and  ascending  pharjmgeal  branches  ( J  a  c  o  b  s  o  n) . 
This,  however,  is  usually  very  difficult;  moreover,  as  has  been  shown 
(Harrison  C  r  i  p  p  s),  the  fear  of  secondary  hemorrhage  is  not  well 
founded. 

The  internal  carotid  artery  very  rarely  requires  ligation.  Hemorrhage 
from  the  vessel  in  the  carotid  canal,  erosion  of  the  vessel  from  disease  of 
the  bone,  wounds  of  the  vessel  (Lee),  and  traumatic  aneurism  (B  r  i  g  g  s) 
constitute  the  principal  indications.  The  vessel  has  also  been  tied  for  secon- 
dary hemorrhage  following  removal  of  the  lower  jaw  (Sands).  The  col- 
lateral circulation  is  almost  immediately  restored  through  the  branches  of  the 
vessel  of  the  opposite  side  in  the  circle  of  Willis  and  the  vertebrals.  The 
common  carotid  has  been  ligated  by  mistake  for  the  internal  carotid  (B  r  o  c  a). 

Operation. — The  line  of  the  artery  is  practically  the  same  as  that  of  the 
external  carotid.  The  latter  vessel  is  first  exposed  and  then  drawn  imvard  with 
a  small  blunt  hook.  The  digastric  muscle  is  drawm  upward,  when  the  internal 
carotid  is  brought  into  view.  The  latter  vessel  is  secured  at  its  commencement 
close  to  the  bifurcation.  The  needle  is  passed  from  without  inward,  and  the 
same  care  is  taken  to  avoid  injury  to  the  internal  jugular  vein  and  the  pneumo- 
gastric  nerve  as  in  ligation  of  the  common  carotid. 

Ligation  of  the  Innominate  Artery.— The  only  indication  for  liga- 
tion of  the  innominate  artery  is  aneurism  of  this  vessel  at  the  point  of  its 
division  into  the  right  common  carotid.  The  operation  was  first  performed  by 
Valentine  M  o  1 1  ,  of  New  York,  in  1818.  Though  aneurism  of  this 
vessel  is  not  rare,  in  a  large  proportion  of  cases  the  diseased  condition  occupies 
the  entire  area  of  the  arter\\  Among  the  24  reported  cases  ( A  s  h  h  u  r  s  t)  but 
one  proved  successful,  that  of  S  m  i  t  h  ,  of  New^  Orleans  (1864).  M  i  t  c  h  e  1 
Banks's  case  survived  fifteen  weeks.  Death  takes  place  from  secondary 
hemorrhage  from  the  peripheral  end,  the  powerful  collateral  circulation  through 
the  common  carotid,  subclavian,  and  vertebral  preventing  the  formation  of  a 
firm  clot  (L  e  F  o  r  t).  In  S  m  i  t  h  '  s  case  this  also  occurred,  though  the  right 
common  carotid  was  simultaneously  ligated.     The  patient  was  saved  by  prompt 


636  SURGERY   OF   THE   NECK 

ligation  of  the  vertebral  artery.     In  future  cases  the  aseptic  procedure  may 
obviate  this  danger.     The  operation  is  ver}^  difficult  of  performance. 

Operation. — The  skin  incision  commences  at  the  left  sternoclavicular 
articulation,  and  follows,  with  a  sliglit  curve  downward,  the  upper  edge  of  the 
sternum  until  the  light  sternoclavicular  articulation  is  reached.  This  is  met 
by  a  vertical  incision  three  inches  long  which  follows  the  anterior  edge  of  the 
sternomastoid  muscle.  The  superficial  fascia  is  divided  in  the  same  lines. 
The  flap  is  dissected  up  and  the  sternohyoid  and  sternothyroid  muscles  divided 
close  to  the  sternum.  In  order  to  gain  more  room  the  sternomastoid  may  be 
partly  cUvided,  care  being  taken  to  avoid  injuring  the  anterior  jugular  vein. 
If  met,  it  is  to  be  divided  between  two  ligatures. 

The  deep  cervical  fascia  is  now  incised  in  the  direction  of  the  original  wound 
and  the  common  carotid  sought  for  and  its  sheath  opened  as  low  dowm  as  pos- 
sible. This  vessel  is  now^  traced  downward  until  the  bifurcation  of  the  innomi- 
nate is  reached.  The  vessel  usually  lies  behind  the  right  sternoclavicular 
articulation,  in  the  mass  of  fat  and  connective  tissue  extending  downward  to 
the  anterior  mediastinum  and  upward  to  the  trachea  and  esophagus.  In  fol- 
lowing the  arterA'  downward,  when  it  is  situated  low  down,  the  head  should  be 
slightly  flexed  and  the  search  aided  by  a  head-band  reflector  (J  a  c  o  b  s  o  n). 
The  innominate  vein  and  pnemnogastric  nerv^e  should  be  drawn  outw^ard  and 
injury-  to  the  pleura  avoided  by  keeping  the  needle  closely  applied  to  the  artery. 
The  needle  is  to  be  passed  from  without  inward  and  slightly  from  above  down- 
ward. Special  difficulties  are  met  when  the  j^arts  surrounding  the  vessel  are 
matted  together  by  adhesions.  The  operation  may  have  to  be  abandoned  on 
account  of  extensive  disease  of  the  artery,  in  which  case  Bras  dor's  opera- 
tion of  ligation  of  the  right  common  carotid  and  subclavian  should  be  substi- 
tuted. 

In  order  to  avoid  secondary-  hemorrhage,  the  common  carotid  and  A'ertebral 
should  be  ligated  at  the  same  time.  Sterilized  floss  silk  or  chromicized  catgut 
should  be  employed  as  ligature  material. 

Ligation  of  the  Subclavian  Artery. — Ligation  of  this  Aessel  may 
be  demanded  by  certain  injuries  and  diseases  of  the  upper  extremity, 
tumors  of  the  axiUa  and  operations  for  their  removal,  and  by  hemorrhage. 
The  vessel  has  also  been  ligated  in  cases  in  which  chstal  ligation  is  employed  in 
innominate  and  aortic  aneurism,  as  a  preliminary  step  in  excision  of  the 
scapula,  and  in  amputation  of  the  entire  upper  extremity.  The  mortality  is 
almost  50  per  cent  (W  .  Koch).  Though  the  cause  of  death  in  most  of  the 
fatal  cases  has  been  due  to  the  condition  for  which  the  ligature  was  applied,  yet 
the  ligation  itself  is  not  without  danger.  In  case  the  wound  suppurates, 
suppurative  pleuritis  may  cause  death.  The  pleura  may  be  injured  and  pneu- 
mothorax result. 

The  vessel  may  be  exposed  and  secured  in  its  second  portion,  where  it  lies 
behind  the  scalenus  anticus;  in  its  third  portion  between  the  external  edge 
of  the  scalenus  anticus  and  the  outer  border  of  the  first  rib ;  and,  finally,  below 
the  c\2i\ic\e  at  the  upper  portion  of  the  anterior  thoracic  wall.  The  first- 
named  situation  is  very  unfavorable  on  account  of  the  proximity  of  numerous 
and  large  branches  (vertebral,  internal  mammary,  thyroid  axis,  and  the  supe- 
rior intercostal),  the  necessity  for  division  of  the  scalenus  anticus  muscle  and 
the  consequent  risks  of  injuring  the  phrenic  nerve  and  the  internal  jugular 


THE    LATERAL    REGION'    OF    THE    NECK  637 

vein,  and  the  dangers  of  injury  to  the  j^leura,  with  which  the  artery  is  in  contact 
below.  The  third  part  is  the  most  fa\-oral)le  point  for  a})phcation  of  the  hga- 
ture.  Here  the  artery  is  more  superficial  and  does  not  send  off  any  branches ;  as 
far  as  present  surgical  experience  extends,  it  is  the  only  justifiable  point  to 
apply  a  ligature  except  when  the  operation  is  performed  in  cases  of  tumors  of 
the  axilla  (secondary  carcinomatous  deposits  involving  the  vessel  and  demand- 
ing its  resection).  This  artery  was  first  successfullv  ligated  bv  Post  ,  of 
New  York  (1817). 

Operation. — The  patient's  head  is  turned  toward  the  opposite  shoulder 
and  the  neck  is  slightly  flexed  laterally.  The  corresponding  arm  is  drawn 
downward  and  the  shoulder  depressed.  The  skin  of  the  posterior  triangle  of  the 
neck  is  drawn  downward  and  an  incision  three  inches  in  length  is  made  through 
the  skin  and  platysma  down  on  the  clavicle.  The  external  jugular  vein  is 
avoided  by  this  maneuver.  When  the  traction  is  withdrawn,  this  incision 
should  extend  from  the  trapezius  to  the  sternomastoid.  To  this  may  be 
added  a  short  vertical  incision.  The  deep  cervical  fascia  is  now  incised 
in  the  length  of  the  original  w^ound.  If  the  external  jugular  vein  comes  into 
view,  it  is  to  be  displaced  outward  and  di^dded  between  two  Hgatures. 
The  omohyoid  muscle  is  retracted  upward  and  outward.  The  edge  of  the 
scalenus  anticus  muscle  is  now  sought  for  and  the  finger  passed  along  its  edge 
until  the  tulaercle  of  the  first  rib  is  identified.  The  brachial  plexus  is  identified 
with  the  finger  as  it  passes  from  above  downward  and  outward,  limiting  the 
supraclavicular  fossa  above.  The  vessel  itself  is  identified  by  its  pulsation  as 
it  rests  on  the  bone.  The  artery  is  now  cleared  by  careful  dissection  and  an  un- 
threaded aneurism  needle  passed  from  above  doT\mward  and  from  behind 
forward.  The  index-finger  serves  as  a  guide  for  the  passage  of  the  needle 
and  at  the  same  time  protects  the  vein  from  injury.  Care  is  necessary-  not  to 
wound  the  pleura.     The  needle  is  now  threaded  and  withdrawn. 

The  vertebral  artery  is  accessible  for  about  an  inch  and  a  cparter  of  its 
length.  It  can  be  reached  only  just  below  the  transverse  process  of  the  sixth 
cervical  vertebra  and  before  it  enters  the  canal  of  this  process.  It  was  first  tied 
by  M  a  i  s  o  n  n  e  u  V  e  (1852).  The  first  successful  case  is  that  of  Smith, 
of  New  Orleans  {vide  supra).  Alexander,  of  Liverpool,  Hgated  the  verte- 
bral in  36  cases  of  epilepsy.  Of  these,  33  recovered  from  the  operation.  The 
strong  collateral  current  from  the  vessel  of  the  opposite  side  through  the  basilar 
artery  usualh"  renders  the  operation  useless.  The  artery  is  reached  by  an 
incision  three  inches  in  length,  commencing  at  the  clavicle  and  extending  along 
the  posterior  border  of  the  sternomastoid.  The  transverse  process  of  the  sixth 
cervical  vertelira  is  the  guide  to  the  vessel.  It  is  usually  necessary  to  divide 
a  portion  of  the  clavicular  attachment  of  the  sternomastoid.  The  vertebral 
vein  lies  in  front  of  the  artery.  On  the  left  side  the  thoracic  duct  may  be 
endangered. 

Stretching  of  the  Brachial  Plexus.— For  intractable  neuralgia  of  the 
arm  the  brachial  plexus  has  been  stretched  at  the  points  where  its  roots 
leave  the  intervertebral  canals.  The  incision  begins  at  the  middle  of  the 
sternomastoid,  extends  downward  for  about  two  inches,  and  terminates  about 
an  inch  and  a  half  from  the  posterior  edge  of  the  latter  muscle.  The  external 
jugular  vein  is  to  be  compressed  above  the  clavicle  b}'  an  assistant.  The 
transversalis  coUi  crosses  the  plexus  horizontaUy  in  the  lower  third  of  the 


638  SURGERY    OF   THE    NECK 

wound.  I'hc  plexus  is  lifted  b}'  means  of  a  blunt  hook  and  freed  by  the  index- 
finger,  isolated,  and  stretched  in  l)()th  directions. 

Stretching  of  the  cervical  plexus  is  indicated  in  neuralgia  in  the  occip- 
ital, auricular,  and  supraclavicular  regions.  Branches  of  the  cervical  plexus 
may  be  reached  by  an  incision  along  the  posterior  edge  of  the  stemo- 
mastoid;  from  the  middle  of  this  muscle  upward  the  branches  are  followed 
behind  the  muscle  to  their  points  of  origin  from  the  plexus.  Great  care  is 
necessary  to  avoid  injury  to  the  internal  jugular  vein. 

Intraspinal  Nerve  Stretching  and  Neurectomy. — The  posterior  or 
sensory  roots  of  spinal  nerves  have  been  stretched,  as  well  as  divided  and 
resected,  for  persistent  neuralgia  (Dana,  Abbe,  1888).  Portions  of  the 
arches  of  the  vertebrae  are  removed  and  the  dura  exposed  for  two  inches.  The 
latter  is  not  opened.  The  intervertel^ral  foramina  are  explored  by  a  curved 
blunt  hook  ancl  the  nerves  stretched,  divided,  or  resected.  The  results  of  the 
operation  thus  far  have  not  been  very  satisfactorv'. 

Neurectomy  of  the  Spinal  Accessory  Nerve. — Clonic  spasm  in  the  area  of 
distribution  of  the  spinal  accessory  has  been  treated  by  neurectomy  of  this 
nerve.  The  point  where  the  nerve  passes  into  the  sternomastoid  corresponds 
to  almost  the  exact  middle  of  this  muscle  (i.  e.,  half-way  between  the  mastoid 
process  and  the  inner  extremity  of  the  clavicle).  The  posterior  edge  of  the 
muscle  is  exposed  and  the  nerve  sought  for  at  the  point  where  it  passes  from 
within  outward  to  the  sternomastoid  ancl  thence  to  the  trapezius.  The  nerve 
is  resected  here  without  difficulty.  The  results  of  the  operation  have  thus  far 
been  satisfactory. 

Operations  for  the  Removal  of  Tumors  of  the  Neck. — The  extirpation 
of  tuberculous  lymphatic  glands  is  indicated  for  the  jorevention  of  general 
tuberculosis.  Early  operation  is  preferable,  not  only  because  of  the  greater  pro- 
tection afforded  but  on  account  of  ease  of  performance  as  well.  In  late  cases 
the  glands  become  attached  to  important  surrounding  parts.  Curved  incisions 
should  be  employed,  wherever  practicable,  a  flap  being  turned  back  to  give 
access  to  the  underlying  parts  and  the  glands  isolated  wdth  the  thin  wedge- 
shaped  handle  of  the  scalpel,  rather  than  with  its  blade.  The  closed  blades  of 
a  curved  blunt  scissors  will  be  found  very  useful. 

The  suprahyoid  groujD  is  removed  without  difficulty.  The  only  vessel 
rec|uiring  ligation  is  the  small  mylohyoid  artery.  The  submaxillary  lymphatic 
glands  are  more  difficult  of  extirpation.  The  facial  artery  is  frequent!}'  in- 
jured. This  group  may  extend  downward  to  the  lingual  artery  and  outward 
to  the  external  carotid.  The  submaxillary  salivary  gland  is  frecjuently  involved 
in  the  mass  and  is  removed  as  well. 

Extirpation  of  the  upper  deep  cervical  or  supracarotid  group  is  still 
more  difficult.  Fortunately,  in  most  cases  the  connective  tissue  is  not  very 
intimately  adherent  at  the  posterior  aspect"  of  the  group  or  in  the  direction  of 
the  vessels.  Ligation  of  the  common  carotid  artery  is  seldom  necessary, 
though  its  wall  is  freciuently  exposed.  The  edge  of  the  knife  should  never  be 
directed  toward  the  vessels. 

The  lower  deep  cervical  glands  are  exceptionally  difficult  of  removal  by 
reason  of  their  intimate  relation  with  the  internal  jugiilar  vein  and  their  fre- 
quent adhesions  to  it.     The  portion  involved  in  the  latter  is  to  be  left  till  the 


THE    LATERAL    REGION    OF    THE    NECK  639 

last;  then,  if  the  vein  is  injured,  th(>  wound  in  the  latter  can  be  grasped  by 
hemostatic  forcejis  and  a  lateral  ligature  applied. 

The  occipital  and  supraclavicular  groups  are  usually  easy  of  extirpation. 
Cdands  lying  on  the  internal  carotid  artery  and  those  constituting  the  prever- 
tebral group  are  exceeding!}'  diilicult  of  removal,  and  the  impossibility  of  reach- 
ing all  of  the  diseased  glandular  structures  nullifies  the  entire  operation. 

In  case  these  glands  have  suppurated,  complete  removal  may  be  impossible, 
lender  these  circumstances  the  abscess  cavity  is  to  be  evacuated  and  its  walls 
curetted,  vigorously  ruljbcd  with  iodoform  gauze,  and  only  partially  closed. 

Carcinoma  and  Sarcoma. — The  justifiability  of  removal  of  malignant 
tumors  of  the  neck  wdll  depend  on  whether  or  not  they  are  movable  on  the 
underl^-ing  parts.  The  absence  of  mobilit}^  on  the  vertebral  column,  or  only 
a  slight  mobility,  as  a  rule  is  a  contraindication  to  extirpation.  Their  size  and 
location  must  also  enter  into  the  question. 

Before  exposing  the  growth  it  is  not  always  possible  to  decide  as  to  the 
practicability  of  removal.  Sometimes  the  tumor  is  not  attached  to  the  carotids, 
but  only  lies  against  them  or  the  internal  jugular  vein.  Where  the  vessels  are 
displaced  by  the  growth,  they  will  often  be  found  intimately  adherent  to  it. 
In  case  of  doubt  the  operation  should  always  begin  by  exposing  the  common 
carotid  artery  below  the  tumor  and  passing  a  provisional  ligature  around  the 
vessel.     By  adopting  this  precaution  excessive  hemorrhage  may  be  prevented. 

When  portions  of  the  carotid  artery  or  the  internal  jugular  vein  are  involved 
in  the  growth  and  reciuire  removal,  this  must  be  accomplished  between  two  liga- 
tures. When  the  vein  is  accidentally  wounded  low  down,  instant  digital  com- 
pression must  be  made  to  prevent  entrance  of  air.  The  bleeding  point  is  then  to 
be  grasped  beneath  the  compressing  finger  by  broad-bladed  hemostatic  forcej^s, 
and  the  vessel  secured  hj  a  ligature.  It  is  still  an  open  cjuestion  as  to  whether  or 
not  the  operation  is  to  be  abandoned  W'hen  the  pneumogastric  is  involved. 
Instances  of  complete  division  of  this  nerve  are  recorded  in  which  the  patient 
survived.  If  the  operation  is  to  be  proceeded  with,  no  portion  of  the  tumor 
is  to  be  left  behind.  The  necessity  for  abandoning  the  operation  before  com- 
pletion is  always  an  unfortunate  circumstance,  for  the  reason  that  septic  con- 
ditions usually  supervene  and  rapid  growth  of  the  remaining  portion  always 
occurs.  The  removal  of  a  growth  that  has  begun  to  break  down  should  not  be 
undertaken.  The  inevitably  fatal  result  may  sometimes  be  postponed,  how- 
ever, by  removing  septic  foci  with  the  sharp  spoon  and  packing  with  iodoform  or 
other  antiseptic  gauze. 

Even  after  apparent  complete  extirpation  and  perfect  healing  recurrence  is 
the  rule  and  immunity  the  exception. 

Branchial  Fistula. — Congenital  fistulas  of  the  neck  result  from  incom- 
plete closure  of  the  branchial  clefts  (see  page  237).  In  the  great  majority  of 
cases  they  arise  from  the  fourth  branciiial  cleft,  in  wliich  case  the  external 
opening  is  situated  just  above  the  sternoclavicular  articulation,  and  on  either 
the  outer  or  the  inner  edge  of  the  sternal  portion  of  the  sternomastoid 
muscle.  When  they  arise  from  the  upper  clefts,  the  external  opening  is  found 
on  a  level  with  either  the  cricoid  cartilage  or  the  thyroid  cartilage  and  at  the 
inner  edge  of  the  sternomastoid.  When  found  high  up,  congenital  ear  fistulas 
(Hensinger)  or  atresia  of  the  external  auditory  canal,  as  weU  as  mal- 
formations of  the  external  ear,  may  coexist  (V  i  r  c  h  o  w). 


640  SURGERY   OF   THE   NECK 

In  about  one-third  of  the  cases  the  fistula  is  double-sided.  In  the  one-sided 
cases  it  is  most  frequently  found  on  the  right  side.  It  may  be  complete  or 
incomj)lete.  The  fistulous  canal  is  lined  with  mucous  membrane ;  its  external 
opening  is  usually  very  small  and  is  marked  by  a  slight  elevation  or  a  reddish 
ring  of  mucous  membrane.  The  secretion  from  the  canal  may  amount  to  only 
a  slight  moisture ;  generally  there  is  a  scanty,  stringy,  saliva-like  fluid,  which, 
under  some  circumstances,  may  become  purulent.  Fetal  cartilage  may  be 
found  in  the  depths  of  the  fistula. 

When  the  fistula  is  complete,  it  leads  under  the  skin  in  the  direction  of  the 
greater  cornu  of  the  hyoid  bone,  and  thence  beneath  the  lower  margin  of  the 
inferior  maxilla  to  open  in  the  pharynx  in  the  neighborhood  of  the  tonsil.  The 
canal  is  wider  than  either  of  its  openings  and  a  dilated  portion  is  sometimes 
found  near  the  external  opening.  When  incomplete,  it  ends  blindly  a  short 
distance  above  the  aperture,  and  from  retention  of  secretion  it  may  lead  to  the 
formation  of  a  small  cyst. 

Females  are  affected  oftener  than  males.  Hereditary  influences  are  some- 
times observed.  Ascherson  records  eight  cases  occurring  in  three  genera- 
tions of  one  and  the  same  family. 

The  treatment  of  complete  fistula  is  very  unsatisfactory,  owing  to  the 
difficulty  of  destroying  the  mucous  lining.  Cauterization,  as  well  as  the  injec- 
tion of  iodin,  gives  but  indifferent  results.  Excision  of  the  fistulous  track  is 
usually  impracticable,  and  if  successful  leaves  an  amount  of  scarring  as  objec- 
tionable as  the  fistula  itself.  Incomplete  and  shallow  fistulas  may  be  dissected 
out  without  difficulty. 

Cervical  Sympathectomy.— This  operation  has  been  recommended  for 
glaucoma  and  for  Jacksonian  epilepsy  (Alexander;  Jonnescu). 
The  incision  is  the  same  as  for  ligation  of  the  carotid  artery.* 

The  superior  ganglion  is  first  sought.  The  internal  jugular  vein,  pneu- 
mogastric  nerve,  and  internal  carotid  artery  are  identified  in  turn  and  drawn 
anteriorly;  the  sternomastoid  is  retracted  posteriorly.  The  cervical  sym- 
pathetic cord  is  differentiated  from  the  pneumogastric  and  superior  laryngeal 
nerves,  and  traced  upward  until  the  lower  border  of  the  ganglion  is  reached. 
This  appears  as  a  reddish-gray  fusiform  swelling  on  the  cord  about  3  centi- 
meters in  length,  lying  posteriorly  to  the  commencement  of  the  internal  carotid 
and  on  the  rectus  capitis  anticus  major  muscle.  The  ganglion  is  carefuUv 
cleared  and  secured  by  catch  forceps,  and  slow  and  careful  traction  is  made  until 
its  upper  border  appears,  when  the  cord  above  is  severed.  Sometimes  the  cord 
and  ganglion  come  away  by  avulsion. 

The  cord  is  now  .traced  downward  until  the  middle  ganglion  is  reached. 
This  is  situated  opposite  Chassaignac's  tubercle  in  front  of  or  on  the 
inferior  thyroid  branch  of  the  subclavian  and  about  on  a  level  with  the  omo- 
hyoid muscle.  The  ganghon  is  detached  from  its  cardiac  filaments  and  the  cord 
below  the  ganglion  traced  downward. 

The  inferior  ganglion  is  in  relation  to  the  superior  intercostal  branch  of  the 
subclavian  artery,  and  in  order  to  reach  it  with  safety  the  skin  incision  is  ex- 
tended and  the  artery  exposed  in  its  first  portion.     On  the  left  side  the  ganglion 

*  B  r  a  u  n  ,  of  Gottingen,  operated  by  an  incision  placed  posterior  to  the  sterno- 
mastoid. He  found  difficulty  in  locating  the  upper  ganglion,  and,  because  of  the  difficul- 
ties and  dangers,  abandoned  the  attempt  to  remove  the  lower  ganglion. 


THE    CERVICAL   VKRTl^BRAE  641 

lies  behind  the  sulx'laAian  and  on  ihc  inner  side  of  the  intercostal  artery.  On 
the  ri<2;ht  side  the  artery  is  Ijehind  the  muscle,  and  the  ganglion  is  in  relation 
with  the  inner  edge  of  the  latter,  and  lies  Ijetween  the  base  of  the  transverse 
process  of  the  last  cervical  vertebra  and  the  neck  of  the  first  rib.  Here  the 
greatest  care  is  required  to  avoid  injury  to  the  vessels  and  to  the  phrenic  nerve 
as  it  passes  in  front  of  the  subclavian  to  the  inner  side  of  the  scalenus  anticus. 
Once  the  ganglion  is  identified  it  is  forced  upward  by  gentle  traction  and 
separated  from  the  cord  Ijelow  by  avulsion. 

In  case  the  operator  succeeds  in  identifying  the  ganglion  readily  on  the  first 
side  attacked,  both  sides  may  be  operated  on  at  the  same  sitting.  Visual 
disturbances  due  to  interference  with  the  sympathetic  supply  to  the  ciliary 
muscle  are  more  or  less  pronounced  and  in  some  instances  irremediable  and 
permanent. 

In  four  cases  in  which  I  operated  for  epilepsy  all  recovered  from  the  opera- 
tion. In  the  first  case  the  patient  died  in  the  status  epilepticus  before  the 
second  operation  could  be  performed.  In  the  other  three  cases  both  sides  were 
operated  on  at  the  same  sitting.  In  the  first  of  these  no  benefit  was  derived. 
In  the  second  the  patient,  an  exceedingly  sensitive  youth,  was  cured,  but  he 
committed  suicide  in  the  following  year  in  a  fit  of  mental  despondency  incident 
to  erratic  and  intractable  visual  disturbances  following  the  operation.  The 
fourth  case  could  not  be  traced  beyond  three  months  after  the  operation,  up 
to  which  time  he  had  had  no  return  of  the  convulsions. 


THE  CERVICAL  VERTEBRAE 

Injuries  of  the  spine  in  general,  like  those  of  the  skull,  derive  most  of  their 
importance  from  the  associated  injury  of  the  contained  nerve  centers  and 
tnmks.  In  addition  to  this,  the  function  of  the  spine  as  a  support  to  the  head 
is  interfered  with. 

Fracture  of  the  Cervical  Vertebrae.— The  body  of  the  vertebra  is 
broken  in  a  little  more  than  one-half  of  the  cases;  in  the  remainder  the  arches 
are  broken  (Gurlt).  Fracture  of  the  arches  is  more  frequent  above  the 
middle  of  the  cervical  region,  and  fracture  of  the  bodies  below  this  point. 
Simultaneous  fractures  of  two  or  more  vertebrae  occur  not  infrec|uently.  The 
axis  is  more  frequently  broken  than  the  atlas,  and  the  odontoid  process  is  some- 
times broken  alone.  The  body  of  the  axis  is  most  frequently  broken  about  a 
fourth  of  an  inch  below  the  neck  of  the  process.  Fractures  of  the  spinous 
processes  occur,  particularly  of  the  seventh. 

In  fracture  below  the  fourth  cervical  vertebra  the  paralysis  wall  usually 
affect  both  arms.  The  anesthesia  may  be  asymmetric  at  first;  the  asymmetry, 
however,  soon  disappears  as  degenei-ative  changes  progress.  A  hyperesthetic 
area  may  be  noted  in  the  parts  supplied  from  immediately  above  the  injury 
on  account  of  irritation  of  the  latter.  Owing  to  the  length  of  the  course  of  the 
involved  nerves  within  the  spinal  canal,  the  area  of  both  motor  and  sensory 
paralysis  will  be  lower  than  the  point  of  injury  to  the  cord.  A  differential 
diagnosis  of  fracture  and  dislocation  is  frequently  impossible. 

In  cases  of  fracture  of  the  odontoid  process,  the  head  is  held  rigidly  fixed, 
and,  when  accompanied  l)y  displacement,  the  lar^mx  is  unduh^  prominent;  the 
voice  sounds  may  be  altered.  The  posterior  wall  of  the  pharvnx  may  be  pushed 
42 


642  SURGERY   OF   THE    NECK 

fdnvai'd  1)}-  the  (lis])lacod  A-(>rtt>ljra.  Crepitus  may  ])c  felt  and  pain  and  ten- 
derness present  in  the  occiput  and  neck. 

Prognosis  and  Complications  of  Injuries  of  the  Cervical  Vertebrae. — 
Both  fracture  and  dislocation  of  the  bodies  of  the  cervical  vertebrae  are  neces- 
sai'il>'  attended  by  a  high  mortality,  owing  to  the  almost  inevitabh'  accompany- 
ing injury  of  the  s])inal  cord  and  the  consequent  severe  disturbance  of  function. 
These  functional  disturbances  decrease  somewhat  in  importance  the  lower  down 
in  the  spinal  column  the  injury  occurs.  They  retain  a  very  serious  import, 
however,  even  low  down  in  the  lumbar  region.  Injuries  below  the  fourth 
cervical  ^•ertebra  ma}'  paralyze  the  respirator}^  muscles  with  the  exception  of 
the  diaphragm  (distribution  of  the  phrenic  nerve).  Severe  injury  above  the 
fourth  vertebra  may  produce  immediate  death  from  complete  paralysis  of 
respiration.  Even  with  preservation  of  the  phrenic  nerve  death  usually  takes 
place  in  a  few  days,  the  patient  dying  of  suffocation  from  final  failure  of  the 
diajjhragm  to  act.  Injuries  sufficiently  low  down  to  leave  all  the  respiratory 
nerves  intact  are  still  usually  followed  by  a  fatal  result  from  paralysis  of  the 
remaining  motor  nerves,  as  well  as  of  the  sensory  nerves. 

When  the  injury  occurs  above  the  fourth  cervical  vertebra  and  the  cord  is 
damaged,  the  injury  may  prove  immediately  fatal;  or  the  patient  may  survive 
for  a  few  hours,  or,  in  the  majority  of  cases,  for  a  fortnight  at  the  most.  Ex- 
ceptionally, patients  may  survive  for  a  longer  period  (Shaw's  case  for  fifteen 
months  and  Hilton's  for  fourteen  years). 

It  is  not  possible  to  determine  at  the  commencement  whether  or  not  lacera- 
tion of  the  cord  has  taken  place.  In  cases  of  contusion  of  the  latter  the  paralysis 
may  be  complete  at  first,  subsequently  improving.  Treatment  should  therefore 
be  instituted  in  such  cases  and  continued  as  long  as  the  patient  remains  alive. 
Most  frequently,  however,  the  cord  is  lacerated,  as  revealed  by  the  autopsy. 
Even  when  the  cord  escapes  laceration,  contusion  of  this  structure,  hemor- 
rhage, and  laceration  of  the  roots  of  the  spinal  nerves  lead  to  inflammatory 
softening  of  the  cord,  which  finally  extends  to  the  uninjured  portions.  This 
is  announced  by  a  rise  in  temperature,  which  sometimes  occurs  suddenly;  it 
is  sometimes  preceded  by  an  abnormally  low  temperature. 

Treatment  of  Fractures  of  the  Cervical  Vertebrae. — The  spine  should  be 
gently  straightened,  the  patient  placed  on  a  water-bed,  and  every  precaution 
taken  to  prevent  bedsores.  The  bladder  should  be  emptied  every  six  or  eight 
hours.  Where  there  is  palpable  deformity,  attempts  should  be  made  at 
rectification.  This  should  be  attempted  by  extension  and  counter-extension, 
the  patient  lying  on  his  back,  and  manipulation  at  the  site  of  fracture.  The 
chin  and  collar  portion  of  S  a  y  r  e  '  s  suspension  apparatus  may  be  used  for 
extension,  and  counter-extension  maintained  by  raising  the  head  of  the  bed,  a 
rubber  sheet  being  used  with  boric  acid  sprinkled  on  it  to  prevent  friction. 

Resection  of  the  spine,  or  laminectomy,  has  been  frequently  resorted  to 
of  late  years,  either  as  an  immediate  or  as  a  secondary  operation.  Postmortem 
examinations  have  shown  that  even  where  the  cord  is  not  lacerated,  pressure 
from  displacement  may  produce  irremediable  softening  in  from  twenty-four  to 
forty -eight  hours.  The  mortality  after  laminectomy  is  48  per  cent  (W  h  i  t  e). 
The  immediate  operation  is  indicated  particularly  where  fracture  of  the  arches 
can  be  made  out.  The  operation  may  still  be  of  service  when  the  body  is 
broken  and  displaced,  the  compression  being  due  to  coincident  displacement  of 


THE    CERVICAL    VKUTKBUAE  643 

tlK>  laniiiuu\  Wlicn  ixM-foinuMl  as  a  sccoiulary  operation,  it  is  indicated  by 
failure  of  imi^rovement  in  the  ])aralysis  at  the  end  of  six  weeks,  with 
persistent  s])read  of  l)e(lsores,  incontinence  of  urine  and  cj'stitis  (L  a  u  e  n - 
stein). 

The  indications  for  operative  interference  in  injuries  of  the  osseous 
framework  of  the  spine  areas  foUows;  (1)  in  compound  fractures  for  the 
^enlo^•al  of  foreign  bocUes  and  fragments  of  l)one;  (2)  in  injuries  of  the  arches 
and  spinous  processes,  with  lesions  of  the  cord,  when  bony  fragments  are  driven 
against  the  theca  and  are  liable  to  produce  further  injury  at  every  movement; 
(3)  in  the  rare  cases  where  the  symptoms  are  mainly  due  to  thecal  or  perithecal 
hemorrhage  pressing  upon  the  cord;  (4)  in  pach}-meningitis  and  perimeningitis 
following  an  injury;  (5)  in  cases  where  the  cauda  equina  is  pressed  upon, 
recover}^  maj^  follow  the  relief  of  pressure  by  operation.  (For  the  operation 
of  laminectomv,  see  Vol.  II,  page  2.) 

DISLOCATIONS  OF  THE  CERVICAL  VERTEBRAE 

These  are  more  frequent  than  fractures  in  the  cervical  region,  on  account  of 
the  greater  flexibility  of  this  portion  of  the  spinal  column.  Combined  disloca- 
tion and  fracture  occurs,  however,  the  bony  insertions  of  the  strong  liga- 
mentous structures  giving  wa}'.  Under  these  circumstances  the  fracture  is 
unimportant  as  compared  with  the  dislocation. 

Mechanism  and  Varieties  of  Dislocation.— With  the  exception  of  the 
movements  of  the  atlas  and  axis,  the  movements  of  the  cervical  spine  are 
comprised  in  those  of  flexion  or  bending  forward,  extension  or  bending  back- 
ward, and  abduction  or  lateral  bending,  the  head  approaching  the  shoulder. 
In  the  latter  movement,  when  extreme,  there  is  also  flexion,  these  two  move- 
ments combined  comprising  rotation. 

Dislocation  in  Extension. — Extension  movements  are  more  limited  than 
those  of  flexion,  owing  to  the  tilelike  arrangement  of  the  vertebral  arches. 
Extreme  extension  to  the  point  of  dislocation,  therefore,  presupposes  compres- 
sion and  final  crushing  of  the  arches,  and  after  this,  of  the  cord  as  well.  Cases 
of  this  description  are  rarely  seen  clinically,  death  taking  place  almost  immedi- 
ately. 

Flexion  Dislocation. — In  extreme  flexion  the  arches  are  carried  away 
from  each  other,  the  two  articular  processes  of  the  upper  vertebra  moving 
upward  on  the  two  articular  processes  of  the  lower  vertebra,  being  restrained 
only  by  tension  of  the  ligamentum  subflava.  The  posterior  edge  of  the  upper 
vertebral  body  is  lifted  away  from  the  posterior  edge  of  the  one  l^elow.  With 
the  yielding  of  the  ligaments  between  the  arches  and  the  posterior  portion  of  the 
intervertebral  disc,  and,  perhaps,  the  tearing  away  of  the  bone  (avulsion),  the 
articular  processes  of  the  upper  vertebra  leave  those  of  the  lower  vertebra, 
and  the  former  is  dislocated  forward,  its  articular  processes  resting  in  front  of 
those  of  the  lower.  Reduction  is  then  opposed  because  the  articular  pro- 
cesses of  the  upper  vertebra  become  locked  in  front  of  those  of  the  lower,  from 
which  position  they  must  be  released  before  both  pairs  of  articular  processes 
can  be  brought  again  into  normal  relations  with  each  other. 

Falls  from  a  height,  the  patient  striking  on  the  head,  and  the  falling  of  hea^^ 
masses  of  earth  and  the  like  on  the  head,  are  the  most  common  causes  of 
flexion  dislocations.     Many  of  these  accidents  are  followed  b}'  instant  death 


644  SURGERY   OF   THE    NECK 

from  paralj'sis  of  respiration  or  prove  fatal  before  surgical  assistance  can  be 
summoned. 

The  symptoms  of  flexion  dislocations  are  usuall}-  well  marked  and  unmis- 
takable, though  transverse  fracture  of  a  cervical  vertebra  with  anterior  dis- 
placement may  simulate  flexion  dislocation.  The  head  is  bent  forward,  the 
chin  approaching  the  sternum.  The  neck  muscles  are  spasmodically  con- 
tracted and  bulge  on  each  side.  There  is  a  sudden  interruption  of  the  line  of 
the  spinous  processes  corresponding  to  the  forward  recession  of  the  upper 
vertebra,  and  the  spinous  process  of  the  latter  cannot  be  felt.  Deglutition  is 
interfered  with  and  the  projecting  body  of  the  dislocated  vertebra  can  be  felt 
under  the  pharyngeal  mucous  membrane  posteriorly.  Paralysis  to  a  greater  or 
lesser  extent  is  alwa^'s  present  from  encroachment  upon  the  lumen  of  the  spinal 
canal,  this  varying,  however,  both  in  degree  and  in  extent. 

Finally,  cases  occur  in  which  recoil  takes  place.  In  the  cervical  region 
these  are  believed  to  be  commoner  than  cases  of  persistent  displacement 
(T  h  o  r  b  u  r  n).  The  injury  to  the  cord  may  be  quite  as  great  as  when  per- 
manent displacement  is  present. 

The  treatment  consists  in  an  immediate  attempt  at  reduction,  the  risks 
of  the  procedure  having  been  previously  explained  to  the  patient  or  his  friends, 
as  well  as  the  further  fact  that  even  should  reduction  be  successful  a  fatal 
result  may  yet  occur  from  damage  already  inflicted  on  the  cord.  Simple 
traction  in  the  longitudinal  axis  is  successful  in  many  cases,  all  the  ligaments 
being  torn.  This  latter,  however,  makes  traction  all  the  more  dangerous, 
slight  overtraction  resulting  in  complete  separation  of  the  already  injured 
cord.  Converting  the  flexion  dislocation  into  a  rotation  dislocation  and  then 
reducing  this  (H  u  e  t  e  r)  is  effected  as  follows  :  The  head  is  carried 
strongly  toward  one  shoulder,  and  by  rotating  movements  the  opposite  artic- 
ular process  is  disentangled  from  its  locked  position  with  that  of  the  one  below 
and  replaced  in  its  normal  relation  with  the  latter.  The  head  is  now  abducted 
in  the  opposite  direction  and  the  same  maneuver  repeated,  the  other  articular 
process  being  dislodged  and  finally  reduced. 

Rotation  Dislocation.— With  combinations  of  flexion  and  abduction, 
the  articular  process  of  the  upper  vertebra  may  rest  in  front  of  the  corre- 
sponding articular  process  below  on  the  side  toward  which  abduction  is  made, 
while  the  other  two  articular  processes  bear  their  normal  relation  to  each  other. 
Under  these  circumstances  a  rotation  dislocation  is  said  to  have  occurred. 

This  form  of  dislocation  is  most  commonly  produced  by  a  fall  on  the  head, 
the  weight  of  the  trunk  falling  to  either  one  side  or  the  other  and  bending  to 
the  corresponding  side  the  cervical  portion  of  the  spinal  column.  The  dis- 
location usually  occurs  either  between  the  fourth  and  the  fifth  vertebra  or 
between  the  fifth  and  the  sixth  vertebra. 

The  symptoms  are  not  so  marked  as  in  flexion  dislocation.  The  head  is 
inclined  to  one  side  toward  the  shoulder.  The  neck  muscles  corresponding 
to  the  side  on  which  the  dislocation  has  occurred  are  someAvhat  prominent. 
The  chin  is  not  markedly  rotated  toward  the  opposite  side,  as  in  active  or 
physiologic  abduction  of  the  head.  In  thin  persons  the  shght  displacement 
may  be  felt  on  palpation.  A  prominence,  more  marked  on  one  side  than  on 
the  other,  can  be  felt  on  the  posterior  pharyngeal  wall.  Paralytic  symptoms 
are  not  so  prominent  in  this  dislocation  as  in  that  last  described.     In  most 


THE    CERVICAL    VERTEBRAE  645 

instances,  howovov,  the  roots  of  the  spinal  neT•^'(■s  at  lliis  ])art,  particularly 
those  of  the  brachial  plexus,  are  more  or  less  contused,  and  ])ain  in  the  distri- 
bution of  these,  together  with  formication  and  paretic  conditions,  is  present. 
Hemorrhage,  compression,  or  concussion  of  the  cord  may  likewise  occur, 
though  rarely. 

The  treatment  consists  in  immediate  reduction,  not  only  to  correct  the 
position  of  the  head,  but  to  restore  the  function  of  the  nerves  distributed  to 
the  arm  and  to  avert  progressive  disturbances  in  the  cord  itself.  Reduction 
by  traction  is  positively  eontraindicatecl.  The  dislocation  must  be  reduced 
in  the  way  it  occurred.  The  position  of  superabduction  is  the  cause  of  the 
hooking  of  one  articular  process  in  front  of  the  other,  and  the  head  must  be 
brought  back  in  this  position.  The  manipulation  consists  in  first  forcing  the 
head  in  a  further  position  of  abduction,  or  toward  the  side  to  which  it  already 
tends;  this  releases  the  articular  process.  The  head  is  then  rotated  so  that 
the  ear  of  the  same  side  moves  toward  the  front,  the  ear  of  the  opposite  side 
moving  backward. 

In  the  after-treatment  of  dislocations  of  the  cervical  vertebrae  the  head 
must  be  secured  in  the  median  position.  In  cases  of  rotation  dislocation  a 
simple  pasteboard  cravat  answers  the  purpose.  In  cases  of  flexion  dislocation 
the  destruction  of  the  ligamentous  apparatus  demands  more  trustworthy 
means.  Here  the  plaster-of-Paris  bandage  is  to  be  added,  which  should  encase 
both  shoulders  as  well.  The  patient  should  be  placed  on  a  water-bed  to  prevent 
bedsores  and  the  results  of  the  paralysis  treated  symptomaticallv. 

The  Atlas  and  Axis. — These  occupy  a  special  position,  both  anatomi- 
cally and  clinically.  Flexion  and  extension  are  accomplished  through  the 
atloido-occipital  articulation  and  rotation  through  the  atlo-axoid  articulation. 
These  are  protected  by  very  strong  ligaments,  which,  when  ruptured,  permit 
dislocation,  with  resulting  pressure  on  the  spinal  cord  and  instant  death. 
This  occurs  in  official  hangings,  in  which  the  body,  falling  from  a  sufficient 
height,  is  suddenly  arrested  by  the  rope  encircling  the  neck.  The  ligament 
behind  the  odontoid  process  gives  way  and  the  cord  is  crushed  by  the  backward 
movement  of  the  process.  Fractures  of  the  atlas  and  axis  are  speciaU}^  danger- 
ous from  proximity  of  the  medulla  oblongata. 

In  suicidal  hanging  in  the  majority  of  cases  the  rope  slides  upward  and 
constricts  the  pharynx,  as  well  as  the  large  venous  tnmks,  carotid  artery,  and 
pneumogastric  nerve.     Neither  the  spinal  cord  nor  the  vertebrae  are  injured. 

Dislocations  of  the  odontoid  process  sometimes  occur  with  fatal 
results  from  lifting  children  by  the  head  in  play.  Dislocations  between  the 
atlas  and  the  axis  are  rare  (8  out  of  73  cases  of  dislocations  of  the  cervical  verte- 
brae, B  1  a  s  i  u  s).  Fracture  of  the  odontoid  process  is  somewhat  rare;  the 
process  is  more  resistant  than  the  arch  and  the  transverse  ligament  which  secures 
it  (S  t  e  p  h  e  n   Smith).     The  accident  is  almost  necessarily  fatal. 

INFLAMMATORY  AFFECTIONS  OF  THE  CERVICAL  VERTEBRAL  COLUMN 
Practically,  these  may  be  divided  into  those  which  affect  the  articulations 
of  the  oblique  or  articular  processes,  and  those  which  affect  the  body  of  the 
vertebrae. 

Inflammation  of  the  Lateral  Articulations. — This  is  usually  of  rheu- 
matic origin.     The  inflammation  rarely  passes  beyond  the  stage  of  serous 


646  SURGERY    OF    THE    XECK 

effusion.  It  occurs  more  frequently  in  children  than  in  adults.  Pain  is  re- 
ferred to  the  region  of  the  articular  processes  and  is  always  unilateral.  Tender- 
ness is  present.  The  head  is  abducted  toward  the  diseased  side  (infianunatory 
torticollis),  in  order  to  relax  the  synovial  membrane. 

The  treatment  consists  in  the  application  of  warm  moist  compres.ses. 
Later,  a  jjastcboard  and  starch  bandage  dressing  to  restrict  movements  and 
gradually  restore  the  head  to  its  normal  position  is  applied.  In  chronic  cases 
the  application  of  the  actual  cautery  (thermocautery)  may  be  of  service.  It 
may  be  necessar}^  to  employ  forced  passive  motion  later  on,  if  adhesions 
restrict  the  movements  of  the  head.  The  prognosis  is  u.sually  good,  though 
moderate  wryneck  or  caput  obstipum  has  resulted  from  the  affection. 

Spondylitis  in  the  Cervical  Region. — Inflammation  of  the  bodies  of 
the  cervical  vertebrae  belongs  to  the  large  group  of  affections  known  as  Pott's 
disease.  The  intervertebral  discs  take  only  a  small  part  in  the  affection.  The 
disease  is  essentially  a  granular  (tuberculous)  myelitis  of  the  vertebral  bodies, 
including  the  cancelli,  the  cortical  lamellae,  and  finally  the  periosteum  and  the 
surrounding  tissues.  Abscess  forms  in  the  vertebral  body  and  the  pus  makes  its 
way  in  various  directions  (migratory  abscess). 

The  inflammation  is  almost  exclusively  of  infectious  origin,  the  bacillus  being 
deposited  by  the  blood  in  the  abundant  medullary  tissue  of  the  growing 
bone;  hence  its  more  frecjuent  occurrence  in  childhood.  The  middle  portion 
of  the  cervical  column  is  attacked  with  greatest  frequency,  as  a  rule,  though 
opinions  differ  on  this  point.  Taylor  asserts  that  the  sixth  and  seventh 
cervical  vertebrae  are  more  liable  to  the  disease  than  all  the  other  vertebrae  of 
the  spinal  column. 

Kyphosis  or  permanent  curA^ature  occurs  here  as  in  other  portions  of  the 
spine  attacked,  and  is  due  to  the  fact  that  the  vertebral  body,  after  conden- 
sation of  the  cancellous  and  cortical  substance,  sinks  anteriorly  under  the  in- 
fluence of  the  weight  of  the  head.  The  curve  is  more  uniform  and  convex  than 
in  kyphosis  in  the  dorsal  and  lumbar  regions,  owing  to  the  normal  curve  of  the 
neck,  which,  being  placed  with  its  concave  surface  directed  anteriorly,  con- 
stitutes a  lordosis.  Scoliosis,  or  lateral  curvature,  is  rare  in  the  cervical 
region,  unless  the  focus  of  the  disease  occupies  but  one-half  of  the  vertel^ral 
body.  Under  these  circumstances  a  variety  of  inflammatory  caput  obstipum 
is  present. 

The  spinal  cord  escapes  injury  from  the  fact  that  the  disease  tends  to  extend 
anteriorly  rather  than  toward  the  vertebral  canal.  Resulting  abscesses  also 
incHne  to  pass  anteriorly;  exceptionally,  however,  they  may  follow  the  root  of 
one  or  the  other  lamina  or  arch  and  jorogress  laterally,  in  which  case  the}^  may 
follow  the  roots  of  the  brachial  plexus  and  point  in  the  supraclavicular  region, 
or  even  in  the  axilla.  When  pointing  anteriorly  from  the  lower  cervical 
vertebrae  they  find  their  way  into  the  posterior  mediastinum  and  thence  into  the 
pleura,  or  into  a  bronchus,  causing  death.  From  the  middle  cer-vical  region 
they  reach  the  posterior  pharyngeal  wall,  forming  a  retropharyngeal  abscess. 
With  the  exception  of  the  rather  rare  form  of  the  latter  resulting  from  phleg- 
monous inflammation  of  the  submucous  tissue,  or  suppurating  lymphadenitis 
of  a  retropharyngeal  lymphatic  gland,  retropharjmgeal  abscess  arises  almost 
exclusively  from  Pott's  disease  in  the  cervical  region.  The  projection  of  the 
abscess  into  the  cavity  of  the  pharynx  produces  disturbances  of  deglutition  at 
first,  and  finally  disturbances  of  respiration. 


THE    CERVICAL    VERTEBRAE 


647 


Treatment.  —  Tlio  al)scoss  sliould  be  emptied  early.  This  may  be  done 
through  a  siiiall  incision,  in  onler  to  avoid  entrance  of  pus  into  the  glottic 
opening,  or  the  abscess  may  be  incised  freely  with  the  head  in  the  dependent 
head  position  of  Rose  (see  page  534).  The  walls  of  the  abscess  contain  the 
constrictor  muscles  of  the  pharynx;  hence,  their  elasticity  is  such  as  to 
lead  to  rapid  emptying  and  collapse.  This  favors  early  resolution,  the 
healing  process  frequently  being  completed  in  a  remarkably  short  space  of  time. 

In  the  further  treatment  of  Pott's  disease  in  the  cervical  region  it  will  be 
necessary  to  apply  some  form  of  support  for  the  head  and  vertebral  column. 


Fig.  377. — Jury  Mast. 


Fig.  378. — Anteroposterior  Support   with 
Head-piece. 


This  may  be  accomplished  by  the  use  of  a  jury  mast  attached  to  a  plaster-of- 
Paris  jacket  (Fig.  377),  by  an  anteroposterior  support  with  head-piece  (T  a  }'  1  o  r  , 
Fig.  378),  by  a  padded  leather  collar  (Thomas,  Fig.  379),  or  by  a  brass  wire 
collar  (B  u  r  r  e  1 1  ,  Fig.  380).  The  two  latter  are  rendered  more  efficient  by 
being  attached  to  an  anterolateral  support.  Or  V  o  1  k  m  a  n  n  '  s  method  of 
extension  in  the  recumbent  position  may  be  employed  (Fig.  381). 

Caries  sicca  of  the  medullarv  structure  of  the  atlas  and  axis,  particu- 
larly of  the  latter,  may  occur.  The  inflammation  soon  attacks  the  neighboring 
joints  and  synovitis  ensues.     The  affection  is  more  connnon  in  adults  and  in  old 


648 


SURGERY    OF   THE    NECK 


people  than  in  children.     Caries  with  suppuration  is  uncommon  in  this  region, 
even  in  cases  where  the  autopsy  reveals  extensive  destruction  of  osseous  and 


Fig.  379. — Padded  Leather  Collar. 


Fig.  380. — Bcrrell's  Brass  "Wire  Collar. 


ligamentous  structure  with  fusion  of  all  the  parts  concerned.     The  affection  is 
difficult  of  recognition  in  the  early  stages,  the  symptoms  resembling  those  of 


Fig.  381. — Volkmann's  Method  of  Extension  in  the  Recusibext  Position. 


suboccipital  neuralgia.     When  softening  of  the  ligamentous  structures  has 
taken  place,  the  attitude  of   the  patient,  as  he  grasps  the  head  to  support  it- 


THK  CKKVK'AL  VERTEBRAE  649 

whilo  in  the  act  of  lyinij;  down  or  rising-,  is  characteristic  and  striking.  Sudden 
death  may  occur  from  (hslocation  ((>  out  of  10  cases,  R  u  s  t).  Extensive  par- 
alysis may  occur.  Progressive  myelitis  may  occur  from  gradual)}'  increasing 
pressure  on  the  cord  and  death  take  place  from  this  cause. 

Treatment  is  not  instituted,  as  a  rule,  until  after  softening  of  the  ligaments 
has  taken  place.  Tiie  indications  are  to  support  the  head,  either  by  means  of 
V  o  1  k  m  a  n  n  '  s  extension  in  the  recumbent  position  (Fig.  381)  or  by  means 
of  j\I  a  t  h  i  e  u  '  s  cuirass,  or  one  of  the  head  supports  already  described  (Figs. 
379  and  380).     If  abscesses  form  they  are  to  be  opened  early. 

Bony  ankylosis  of  the  upper  cervical  vertebrae  is  occasionally  found  in 
dissecting-room  sul^jects.     The  affection  is  thus  far  unknown  clinically. 

TUMORS  OF  THE  CERVICAL  VERTEBRAL  COLUMN 

Certain  congenital  clefts  of  the  cervical  vertebral  arches  occur  (spina 
bifida).  Cysts  with  transparent  contents  occupy  these  clefts,  which  communi- 
cate with  the  enlarged  central  canal  of  the  spinal  cord,  and  through  this  with 
the  cerebral  ventricles.  When  a  broad  communication  with  the  fourth  ven- 
tricle is  present,  the  case  presents  a  combination  of  occipital  encephalocele 
and  spina  bifida. 

The  occurrence  of  a  cervical  rib  has  been  mentioned  in  connection  Avith 
aneurism  of  the  subclavian.  A  genuine  exostosis  of  this  al^normal  cervical 
rib  has  been  observed  (Holmes   C  o  o  t  e). 

An  accidental  bursa  mucosa  may  form  over  one  of  the  spinous  processes 
of  the  cervical  vertebrae,  ]3articularly  of  the  seventh.  This  occurs  as  a  slightly 
elevated  convex  sAvelling  filled  with  a  small  amount  of  serosynovial  fluid  sur- 
rounded b}^  somewhat  dense  walls.  It  usually  arises  by  pressure  from  carry- 
ing burdens  upon  the  neck.  Those  greatly  thickened  must  be  treated  by  extir- 
pation. The  milder  forms  may  yield  to  puncture  and  injection  of  tincture  of 
iodin,  or,  this  failing,  free  incision  and  drainage  must  be  practised. 

Sarcomas  may  develop  in  the  cervical  vertebral  bodies  primarily 
either  in  adults  or  in  children.  This,  however,  is  a  rare  occurrence.  They 
are  most  frequently  observed  as  a  secondary  invasion  of  the  disease  and  in 
adults  rather  than  in  children.  In  some  instances  of  supposed  primary  invasion 
the  original  site  of  the  disease  has  been  overlooked.  The  tendency  of  the  growth 
is  to  extend  anteriorly  toward  the  pharyngeal  wall  rather  than  laterally  or 
posteriorly  toward  the  spinal  canal.  The  disease  may  likeAvise  spring  from  the 
periosteum  behind  the  muscular  wall  of  the  pharynx  and  esophagus.  The 
first  symptom  usually  noticed  is  some  difficulty  in  swallowing.  Palpation  of 
the  pharyngeal  wall  reveals  the  presence  of  a  small  tumor,  which  may  be  mis- 
taken for  an  abscess.  Sarcomas  of  the  vertebral  column  grow  rapidly 
and  are  accompanied  b}'  most  agonizing  pain.  When  they  grow  in  an  ante- 
rior direction,  they  may  cause  death  by  starvation  or  suffocation.  If  the 
growth  spreads  laterally,  the  sheath  of  the  carotid  artery  is  involved,  and  death 
may  take  place  from  pressure  on  the  pneumogastric  nerve.  In  view  of  the 
utter  hopelessness  of  these  cases  from  the  operative  standpoint,  treatment  by 
the  mixed  toxic  products  of  the  Streptococcus  er\'sipelatis  and  Bacillus  prodi- 
giosus  may  be  tried  (C  o  1  e  y  ,  see  page  226). 

Carcinoma. — Dissemination  of  carcinoma  elsewhere,  particularly  in  the 
breast,  leads  to  deposits  in  the  spinal  column.     The  cervical  vertebrae  may 


650  SURGERY   OF   THE   NECK 

become  the  seat  of  such  deposits.     The  suffering  is  most  intense,  and  if  the 
patient  lives  long  enough,  suffering  may  be  followed  by  paraplegia. 

TORTICOLLIS  (WRYNECK,  CAPUT  OBSTIPUM) 

These  names  signify  an  alxluctory  contracture  of  the  cervical  vertebral  col- 
umn, in  consequence  of  which  the  axis  of  rotation  of  the  head  is  obliquely  placed 
and  the  chin  is  rotated  toward  the  opposite  shoulder.  The  affection  may  be 
of  cicatricial,  articular,  muscular,  or  central  (cortical)  origin.  The  first 
has  already  been  discussed  (page  624).  The  articular  variety  was  mentioned 
in  connection  with  inflammation  of  the  joints  of  the  cervical  vertebrae,  as  well 
as  in  connection  with  unilateral  spondylitis  of  the  latter. 

Wryneck  of  muscular  origin  is  most  frecjuently  observed  after  breech 
presentations  in  newborn  infants.  It  results  from  partial  rupture  of  the  fibers 
of  the  sternomastoid,  and  its  common  cause  is  traction  on  the  after-coming 
head.  It  may  be  observed  immediately  after  birth,  but  usually  its  manifesta- 
tion is  the  occurrence  of  a  fusiform  swelUng,  consisting  of  a  mass  of  so-called 
muscular  callus,  in  the  course  of  the  sternomastoid  muscle  when  the  child  is 
several  weeks  old.  Tliis  may  be  mistaken  for  a  fibroma  or  an  enchondroma. 
Tills  traumatic  muscular  hyperplasia  usually  disappears  with  treatment, 
after  which  shortening  of  the  muscle  resulting  from  cicatricial  contraction, 
and  perhaps  from  a  voluntary  malposition  of  the  head  in  efforts  to  relieve  pain, 
occurs.  A  peculiar  complication  observed  in  cases  of  long  standing  is  an  arrest 
of  development  of  the  corresponding  side  of  the  head.  This  is  probably  due  to 
pressure  on  the  vessels  and  nerves  of  the  affected  side.  This  as}mimetry 
usually  disappears  in  the  course  of  time  after  correction  of  the  deformity. 

Wryneck  of  Central  Origin  (Spastic  Torticollis,  Tic  Rotatoire).— 
Tills  affection  is  a  neurosis  and  has  its  seat  in  the  brain  cortex.  It  is 
to  be  defined  as  a  disturbance  in  the  motor  area  regulating  movements  of  the 
head.  Symptoms  of  neurasthenia,  and  more  rarely  those  of  hysteria  or  mental 
disease,  may  coexist.  It  is  most  commonly  observed  in  middle-aged  persons 
with  either  an  inherited  neurotic  taint  or  an  acquired  tendency  to  nervous 
disease.  I  have  seen  two  cases  occurring  in  young  girls  as  the  result  of  injury 
(falling  fonx^ard  and  striking  on  the  coronal  suture  of  the  opposite  side).  It  is 
occasionally  oliserved  as  an  occupation  spasm.  The  symptoms  consist  in  a  mor- 
bid contraction  of  certain  muscles  of  the  neck,  which  is  slight  at  first,  of  short 
duration,  and  easily  overcome  by  the  patient.  Later  it  increases  in  severity  and 
the  clonic  contraction  is  converted  into  a  tonic  contraction.  As  a  rule,  the  rota- 
tors of  the  head  are  affected.  The  sternomastoid  of  one  side  and  the  muscles  of 
the  back  of  the  neck  on  the  other  side  are  usually  affected.  Exceptionally  one 
sternomastoid  and  the  muscles  of  both  sides  of  the  neck  are  in"\'olved.  Still 
more  rarely  one  sternomastoid  and  the  cervical  muscles  of  the  same  side  are 
implicated.  Occasionally  the  muscles  of  the  mouth,  face,  shoulder,  and  arm 
take  part  in  the  contractions.  The  vital  prognosis  is  good,  luit  the  outlook 
from  every  other  viewpoint  is  unfavorable. 

True  congenital  wryneck  of  intrauterine  origin  has  been  described 
(G .  Fischer).  Spasmodic  and  paralytic  wiyneck  have  also  been 
described.  Torticollis  has  been  observed  in  children  after  typhoid  fever.  The 
affection  has  been  attributed  to  shortening  of  the  platysma  myoides. 


THE    CERVICAL    VERTEBRAE  651 

Compensatory  scoliosis  in  the  cervical  region  occurs  in  connection 
with  scohosis  in  the  dorsal  region. 

Treatment. — Wryneck  of  muscular  origin  is  best  treated  by  section  of 
the  sternomastoid  muscle.  While  orthopedic  apparatus  serve  a  useful 
purpose  in  maintaining  a  correction  obtained  by  o])eration,  unless  the  latter 
has  been  pre^•iousl^-  performed  they  are  of  little  or  no  avail.  In  the  rare 
cases  which  come  to  the  surgeon  before  shortening  from  contracture  or  defec- 
tive growth  of  the  muscle  occurs,  a  pasteboard  collar,  plaster-of-Paris  ban- 
dage, or  other  means  designed  to  prevent  the  development  of  the  deformity 
may  be  of  service.  The  operation  is  to  be  performed  under  an  anesthetic. 
Either  subcutaneous  division  of  the  muscle  at  its  sternal  and  clavicular  attach- 
ments or  open  section  may  be  made.  The  latter  is  the  safer  and  more  efficient 
method,  but  is  open  to  the  objection,  particularly  in  female  patients,  that  it 
leaves  a  prominent  scar  in  an  undesirable  location.  When  the  former  is 
employed,  the  tenotome  is  introduced  behind  the  muscle  and  the  section  made 
from  behind  forward.  W^hen,  as  is  usually  the  case,  the  entire  width  of  the 
muscle  is  to  be  divided,  it  will  be,  as  a  rule,  necessary  to  introduce  the  tenotome 
a  second  time,  the  portion  which  is  most  shortened  being  divided  first.  An 
assistant  forces  the  patient's  head  toward  the  opposite  shoulder,  in  order  to 
put  the  muscle  on  the  stretch,  and  the  operator  presses  his  thumb  over  the  point 
to  be  divided  so  as  to  feel  when  the  fibers  give  way  and  thus  avoid  injurv'^  to 
the  skin.  Aseptic  dressings  and  plaster-of-Paris  bandages  are  applied  after 
correction  of  the  deformity.  The  question  of  the  application  of  one  or  another 
of  the  forms  of  orthopedic  apparatus  to  maintain  correction  is  to  be  decided 
after  the  healing  of  the  wound.  In  severe  wrvmeck,  as  well  as  in  milder  cases 
of  long  standing,  the  latter  Avill  usually  be  necessary.  In  milder  cases  plaster- 
of-Paris  dressings  suffice  for  the  after-treatment. 

The  treatment  of  spastic  torticollis  is  almost  exclusively  operative.  Anti- 
spasmodics, hydrotherapy,  massage,  electricity,  and  cauterization  have  been 
used  without  success.  Rigid  orthopedic  fixation  appliances  are  useless,  as  far 
as  effecting  a  cure  is  concerned.  Elastic  traction  of  the  head  toward  the  sound 
shoulder  has  been  successfully  used  (H  o  f  f  a).  Stretching  or  resection  of  the 
spinal  accessory  nerve  controls  only  a  part  of  the  affected  muscular  area  and 
leads  to  recovery  in  only  one-fifth  of  the  cases  and  improvement  in  two-fifths, 
leaving  two-fifths  without  any  benefit  whatever.  Section  of  the  upper  cervical 
nerves  (Gardner,  G  i  1 1  e  s  ,  Keen)  has  been  introduced  as  a  substitute 
for  division  of  the  si3inal  accessory.  A  combination  of  these  procedures 
(K  o  c  h  e  r  ,   Richardson,  Walton)  gives  loetter  results. 

In  Kocher's  operation  all  the  muscles  that  are  involved  are  divided.  This 
will  include,  as  a  rule,  the  sternomastoid  of  one  side  and  all  the  cervical  muscles 
of  the  other  side.  In  the  division  of  the  latter  the  obliciuus  capitis  inferior 
must  not  be  overlooked.  The  movements  of  the  head  are  surprisingly  little 
affected  by  these  extensive  myotomies,  and  whatever  impairment  does  take 
place  is  only  temporary.  Relapses  may  occur  and  require  repeated  division 
of  the  muscles  until  the  disease  is  cured.  Gymnastic  exercises  are  to  be  em- 
ployed for  a  considerable  time  after  healing. 

The  operation  is  not  only  palliative,  but  also  curative.  The  cure  is  accom- 
plished by  the  rest  given  to  the  irritable  center  by  division  of  the  muscles,  the 
impulses  being  no  longer  effectual  and  resisted.  In  this  way  the  ec|uilibrium  is 
restored  (F  .   d  e  Q  u  e  r  v  a  i  n). 


SECTION  XVI 
THE  SURGERY  OF  THE  THORAX 

THE  SOFT  PARTS  SURROUNDING  THE  CHEST 

The  skin  and  muscular  structure  of  the  chest  wall  are  seldom  injured  alone. 
Among  the  exceptional  injuries  in  this  class  are  to  be  mentioned  gunshot  wounds 
in  which  the  ball  passes  for  a  short  distance  beneath  the  skin  and  then  emerges, 
producing  a  wound  which  closely  resembles  that  formerly  made  for  the  intro- 
duction of  a  seton,  called  a  seton  gunshot  wound.  The  so-called  contour 
shots  are  also  produced  in  this  way.  In  the  latter  class  of  cases  the  ball  strikes 
the  elastic  ribs  at  a  tangent  and  is  deflected  outward  from  the  ribs  and  the 
intercostal  muscles,  either  issuing  again  after  pursuing  a  short  course  or  re- 
maining. Occasionally  a  ball  will  strike  near  the  sternum  and  pass  around  the 
corresponding  half  of  the  chest,  emerging  near  the  vertebral  column.  It  is 
difficult  to  comprehend  the  precise  mechanism  of  this  injury.  Experiments 
show  that  a  bullet,  traversing  apparently  in  a  circular  direction  for  about  one- 
fifth  of  the  circumference  of  the  thorax,  can  have  its  course  changed  into  a 
straight  line  hdng  outside  of  the  thorax,  by  sudden  rotation  of  the  vertebral 
column  and  elevation  of  the  arm  (Simon,  1871). 

Hemorrhage  from  wounds  of  the  chest  wall  is  not  usually  troublesome. 
The  subclavian  artery  is  the  only  vessel  of  importance  likely  to  be  injured. 
Bleeding  from  this  artery  may  be  arrested  provisionally  by  pressure  above  the 
clavicle  (see  page  626).  Permanent  hemostasis  is  secured  by  ligation  at  the 
point  of  injur}',  or  in  continuity  (see  Ligation  of  the  Subclavian).  The  long 
thoracic  branch  of  the  axillary  artery  passes  almost  vertically  downward  on 
the  lateral  chest  wall,  somewhat  anterior  to  the  axillary  line.  This,  together 
with  the  external  mammary  (superior  thoracic)  branch,  may  be  injured  and 
rec|uire  ligation. 

Penetrating  and  Perforating  Wounds  of  the  Thorax.— Gunshot 
wounds  constitute  the  type  of  this  class  of  injuries.  Many  of  these  when 
inflicted  by  bullets  of  the  larger  calibers  prove  fatal  almost  immediately,  on 
account  of  injury  of  a  large  vessel.  When  both  lungs  are  injured,  fatal  double 
pneumothorax  develops  early.  Death  may  take  place  from  hemorrhage. 
When  but  one  lung  is  injured,  dyspnea,  though  urgent  at  first,  is  relieved  by 
compensatory  expansion  of  the  uninjured  lung. 

Pneumothorax  is  sometimes  prevented  by  outward  prolapse  of  the  injured 
portion  of  lung  into  the  wound  of  the  soft  parts  by  violent  coughing  efforts; 
more  rarely,  in  shot  wounds  by  the  forcing  of  the  pleural  surfaces  temporarily 
on  each  other  in  the  passage  of  the  ball.  The  existence  of  old  adhesions  may 
also  prevent  its  development.  Pyothorax  is  difficult  of  prevention  on  account 
of  frecjuent  infection  from  paz'ticles  of  clothing  carried  along  with  the  bullet  in 
its  passage.     Septic  pneumonia  and  even  gangrene  of  the  lung  may  follow. 

652 


THE    SOFT   PARTS   SURROUNDIXG   TIIK    CHEST  653 

These  complications  usually  end  fatally.  Death  may  also  occur  from  septic 
l^ronchitis,  edema  of  the  hmg,  exhaustion  from  prolonged  suppuration  and 
discharge  from  the  bullet  track,  and  paralysis  of  the  diaphragm. 

When  the  lower  portion  of  the  chest  is  traversed  by  the  missile  and  free 
drainage  is  established,  spontaneous  recovery  may  take  place.  When  the 
hemorrhage  is  due  to  injury  of  the  smaller  vessels  of  the  lung  substance,  the 
pneumothorax  will  usually  arrest  it.  Ice  compresses  to  the  chest  wall  may  be 
employed  if  the  l^leeding  persists.  Resection  of  portions  of  one  or  more  ribs 
for  the  purpose  of  tamponing  with  gauze  and  thus  assuring  collapse  of  lung 
may  be  performed  to  arrest  the  hemorrhage.  Opium  should  be  given, 
and  the  most  perfect  quiet  of  body  and  mind  enjoined.  If  hemorrhage 
from  the  intercostals  is  troublesome  and  tamponing  fails  to  arrest  it,  splintered 
fragments  of  rib  may  be  removed  and  the  vessel  included  in  a  suture  ligature 
(circumsuture).  Fatal  hemorrhage  may  occur  in  injuries  of  the  internal 
mammary  arter}^;  the  bleeding  may  take  place  into  the  pleural  cavity  and 
hence  be  overlooked.  In  such  a  case,  if  the  source  of  the  hemorrhage  is  dis- 
covered, the  wound  must  he  enlarged,  a  portion  of  costal  cartilage  resected,  and 
both  ends  of  the  vessel  secured.  This  last  is  rendered  necessary  by  the  free 
anastomosis  of  this  vessel  with  the  deep  epigastric. 

If  foreign  bodies  that  have  been  carried  along  with  the  missile  can  be 
easily  reached,  they  should  be  removed.  Deep  probing  for  these  will  be  likely 
to  do  more  harm  than  good.  Loose  splinters  of  bone  are  to  be  removed,  and 
the  ends  of  sharp  angular  fragments  resected  or  rounded  ofT  with  the  rongeur. 
The  parts  are  to  be  very  carefully  and  tentatively  irrigated  with  Thiersch's 
borosalicylic  solution.  If  the  irrigating  fluid  reaches  a  bronchial  tube,  as 
evinced  by  the  paroxysms  of  coughing  and  suffocation,  it  must  be  abandoned  at 
once. 

If  the  prolapse  of  lung  is  slight,  the  granulations  in  the  wound  will  cover  it 
in.  If  considerable,  the  prolapsed  part  may  be  hgated  and  cut  away  or  re- 
moved "v\'ith  the  thermocautery.  The  occurrence  of  suppurative  pleurisy  or 
empyema  demands  free  drainage,  with  perhaps  resection  of  one  or  more 
ribs. 

Copious  aseptic  dressing  materials  are  to  be  apjDlied  and  held  in  place  by 
wide  roller  bandages.  The  tight  application  of  broad  strips  of  adhesive  plaster 
encircling  the  chest  will  tend  to  prevent  the  development  of  subcutaneous 
emphysema.  Opium  is  to  be  given  to  allay  pain  and  insure  c^uiet.  Support- 
ing measures  are  indicated. 

With  the  introduction  of  the  modern  small-caliber  mantled  projectile  of  high 
velocity  as  a  weapon  of  war  the  mortality  from  this  class  of  injuries  has  greatly 
diminished.  As  a  result  of  the  smaller  size  of  the  bullet  and  the  diminished 
resistance  of  the  tissues  traversed  the  destructive  effects  are  reduced  to  the 
minimum.  In  the  absence  of  wounds  of  the  heart  and  great  vessels  complete 
and  permanent  recover}'  from  penetrating  and  perforating  wounds  of  the  chest 
is  not  unusual,  as  shown  by  the  most  recent  experiences  in  active  military 
service  (M  a  k  i  n  s). 

Inflammation  of  the  Soft  Parts  of  the  Chest  Walls. — Suppurative 
inflammation  following  gunshot  wounds  of  the  chest  easily  takes  on  a  phleg- 
monous character,  from  infection  of  the  large  and  loose  planes  of  connective 
tissue  which  surround  the  muscular  lavers  of  the  thoracic  wall.     Gunshot 


654  THE  SURGERY  OF  THE  THORAX 

wounds  of  the  upper  dorsal  region  at  the  inner  margin  of  the  trapezius  and 
latissimus  dorsi  are  usuall}'  followed  by  a  suppurative  process  with  a  constant 
tendency  to  extend  in  a  downward  direction,  and  consequent  pocketing  of  pus 
until  the  sacral  region  is  reached.  Repeated  incision,  drainage,  and  antiseptic 
irrigation  are  indicated. 

Subpectoral  Phlegmonous  Inflammation ;  Subpectoral  Abscess. — 
This  is  a  diffuse  suppurative  inflammation  of  the  cormective  tissue  behind 
the  pectoralis  major  muscle.  It  is  usually  the  result  of  a  streptococcus  infec- 
tion, transmitted  through  the  supraclavicular  and  infracla^dcular  h-mphatic 
channels.  The  infection  is  derived  from  Avounds  in  the  neck  or  on  the  cor- 
responding side  of  the  chest ;  a  slight  abrasion  of  the  skin  may  be  the  atrium  of 
infection.  There  may  be  a  histor}^  of  a  strain  or  blow.  A  suppurative  collec- 
tion sometimes  takes  place  behind  the  pectoral  muscle  from  abscesses  within 
the  chest  which  perforate  the  chest  wall,  or  it  may  result  from  necrosis  of 
the  ribs,  of  tuberculous  origin. 

Besides  the  usual  general  symptonxs  of  phlegmonous  inflammation,  the 
patient  complains  of  pain  over  the  corresponding  pectoral  region,  particularly 
when  the  arm  is  moved  so  as  to  bring  the  pectoralis  major  muscle  into  play. 
The  swelling  may  be  so  diffused  beneath  the  muscle  as  to  render  its  recognition 
difficult.  Tenderness,  however,  may  be  pronounced.  The  skin  overlying  the 
pectoralis  major  muscle  remains  unchanged,  except  in  the  rare  instances  in 
which  the  muscle  is  involved  by  an  exceptionally  virulent  infection,  in  which 
case  edema,  and,  finally,  an  inflammatory'  redness  will  be  obser^^ed.  In  rare 
instances  the  jDhlegmonous  character  of  the  inflannnation  may  give  place  to  a 
localized  process,  a  true  abscess  resulting.  The  suppurative  process  tends  to  pass 
in  the  direction  of  the  outer  edge  of  the  pectoralis  major  and  the  Ij'mphatic  glands 
at  this  point  become  infected;  infection  of  the  axillary  glands  may  also  occur. 
The  presence  of  pus  will  be  announced  by  a  soft  swelUng,  "u-ith  tenderness,  and 
later  on  by  involvement  of  the  skin.  Spontaneous  eA'acuation  may  occur  at 
this  point.  In  neglected  cases  general  sepsis,  and  even  metastatic  pyemia,  may 
occur. 

Treatment. — Early  operative  interference  is  imperative.  An  incision 
should  be  made  to  the  outer  border  of  the  pectoralis  major  muscle,  and  the  site 
of  the  suppurative  process  sought  by  passing  the  end  of  an  arteiy  forceps  or 
other  blunt  instrument  beliind  the  great  pectoral  muscle.  Thorough  curetting 
of  the  debris  of  broken-down  tissue  found  to  be  present,  cleansing  with  an 
antiseptic  solution,  and  tube  drainage  are  indicated.  Infected  subpectoral  and 
axillar}'  glands  should  be  dissected  out.  In  cases  of  spontaneous  evacuation 
a  discharging  sinus  is  liable  to  remain.  These  sinuses  are  sometimes  persistent 
in  spite  of  frequent  curettings ;  excision  of  the  entire  suppurating  tract  maybe 
recpired  before  heaUng  can  be  secured. 

When  the  muscle  itself  becomes  involved  and  a  circumscribed  abscess  tends 
to  point  anteriorly,  the  latter  may  be  evacuated  by  a  direct  incision. 

More  or  less  impairment  of  the  movements  of  the  shoulder-joint  may  result 
from  interference  with  the  free  play  of  the  pectoralis  major  muscle.  The 
proper  treatment  for  this  condition  is  massage  and  passive  and  active  move- 
ments of  the  joint. 

Nonsuppurative  Mastitis;  Mastitis  of  the  Newborn.  —  A  pecuhar 
form  of  distention  of  the  breast  occurs  in  newborn  infants  of  both  sexes,  from 


THE    SOFT    PARTS    SURROUNDING    THE    CHEST  655 

which  a  niilklikc  Ihiid  somcluncs  exudes.  It  is  doubtful,  however,  if  this  is  a 
tru(>  mastitis. 

Mastitis  in  the  Male. — A  nonsuppurative  mastitis  is  sometimes  ob- 
served in  male  \'ouths  between  the  ages  of  twelve  and  sixteen  years. 

Mastitis  adolescentium  seems  to  bear  some  relation  to  sexual  devel- 
opment. Slight  contusion  may  be  an  exciting  cause.  The  affection  appears 
as  a  painful,  and  perhaj^s  tender,  swelling  of  the  gland;  a  colostnimlike  fluid 
may  sometimes  Ix^  pressed  out  of  the  latter.  The  condition  is  analogous  to 
menstrual  irritation  of  the  mammary  gland  in  young  females. 

Gynecomastia  is  an  abnormal  development  of  the  mammary  glands  in 
the  male.     It  is  sometimes  accompanied  by  atrophy  of  the  testicles. 

Chronic  mastitis  or  interstitial  paradenitis  is  a  diffuse  proliferation 
and  condensation  of  the  connective  tissue  l)ctween  the  lactiferous  ducts 
and  the  acini.  The  condition  attacks  women  of  forty  and  upward  and 
seems  to  bear  some  relation  to  the  menopause.  It  is  usually  bilateral.  Care 
should  be  taken  not  to  confound  the  disease  with  fibrous  carcinoma  or  scirrhus, 
in  the  cases  in  which  the  disease  is  unilateral,  and  in  wdiich  marked  cicatricial 
contraction  (cirrhosis  of  the  mamma)  has  occurred. 

Treatment. — Extirpation  of  the  breast  is  the  only  safe  remedy.  In  view 
of  the  tendency  toward  malignant  disease  any  persistent  induration  which 
wdthin  a  few  weeks  does  not  show  signs  of  retrogression  under  massage  and 
inunctions  of  a  10  per  cent  ichthyol  lanolin  mixture  should  become  the  subject 
of  at  least  exploratory  incision  and  microscopic  examination.  To  wait  until 
the  glands  are  involved  is,  in  many  instances,  to  doom  the  patient.  Painting 
the  breast  with  tincture  of  iodin  and  injections  of  iodin  solutions  have  been 
recommended. 

Tuberculosis  of  the  mamma  is  very  rare.  But  a  single  case  in  which 
the  diagnosis  was  established  has  been  reported  (P  o  i  r  i  e  r).  Syphiloma  of 
the  breast  is  of  doubtful  occurrence. 

Suppurative  Mastitis.  —  Suppurative  inflammation  of  the  mammary 
gland  is  almost  exclusively  confined  to  nursing  women.  It  occurs,  though 
rarely,  in  newborn  children  of  both  sexes,  when  it  is  not  infrequently  the  result 
of  violent  efforts  on  the  part  of  the  nurse  or  the  midwife  to  force  milk  from  the 
breast  of  the  infant.  It  may  occur  as  a  metastatic  inflammation  during  the 
first  few  days  following  delivery,  and  under  these  circumstances  it  bears  the 
same  relation  to  injuries  of  the  parts  involved  in  the  delivery  as  do  puerperal 
metritis  and  parametritis  resulting  from  septic  infection.  This  is  favored  by 
increased  functional  activity. 

The  inflammation  develops  most  frequently  during  the  third  and  fourth 
weeks  following  delivery,  and  under  these  circumstances  it  is  usually  due  to 
infection  from  fissured  or  abraded  nipples,  or  abrasions  or  eczematous  condi- 
tions about  the  base  of  the  nipple  or  areola.  The  infection  occurs  in  the  con- 
nective tissue  surrounding  the  excretory  ducts  and  the  lobules  of  the  gland. 
The  lymphatic  spaces  surrounding  the  ducts  are  particularly  liable  to  infection. 
The  inflammation  may  radiate  from  the  nipple  to  the  outlying  glandular  struc- 
ture and  an  abscess  form  on  the  periphery  of  the  gland.  As  soon  as  the  sup- 
purative inflammation  extends  beyond  the  limits  of  the  gland  and  invades  the 
loose  connective  tissue  separating  the  latter  from  the  pectoralis  major  muscle, 


656  THE  SURGERY  OF  THE  THORAX 

it  assumes  a  phlegmonous  character  and  retromammary  phlegmon  is  added 
(paramastitis,    P)  i  1 1  r  o  t  h). 

The  symptoms  of  suppurative  mastitis  will  var}-  with  the  extent  and  viru- 
lence of  the  infection.  A  small  focus  of  infection  situated  in  the  gland  itself 
may  give  rise  to  but  a  slight  elevation  of  temperature,  while  a  retromammary 
phlegmon  may  give  rise  to  the  most  serious  disturbances.  In  the  latter  variety 
the  absorption  of  the  septic  products  of  inflammation  is  favored  by  the  pressure 
of  the  overlying  swollen  gland.  In  extensive  suppurative  inflammation  con- 
fined to  the  breast  itself,  the  marked  development  of  lymphatic  vessels  during 
lactation  favors  absorjDtion  of  inflammatory  products.  The  axillary,  and  more 
rarely  the  subclavian  glands  are  affected,  though  these  rarely  suppurate. 

Prognosis. — The  usual  tendency  of  suppurative  mastitis  is  toward  recovery, 
though  suppurative  fistulous  tracts  may  persist  for  a  long  time.  These  may 
communicate  with  the  lactiferous  ducts  and  both  milk  and  pus  discharge  from 
the  orifices  (lacteal  fistula).  The  principal  obstacle  to  healing  is  defective 
drainage,  particularly  in  cases  of  retromammary  phlegmon.  Under  these 
circumstances  new  abscesses  form  constantly,  until  the  entire  gland  and  retro- 
mammary tissues  are  infiltrated  and  riddled  with  discharging  fistulas. 

Treatment. — The  preventive  treatment  consists  in  cleansing  the  nipple 
with  an  antiseptic  solution  after  each  time  of  nursing.  Already  existing  fis- 
sures and  abrasions  are  to  be  touched  with  either  sulfate  of  zinc  or  nitrate  of 
sih-er.  At  the  commencement  of  the  inflammation  the  breast  should  be  covered 
with  compresses  wrung  out  of  a  2.5  per  cent  solution  of  carboHc  acid,  covered 
with  oiled  silk  and  cotton  batting,  and  the  breast  bandaged  in  suspension 
(Fig.  209).  Nursing  should  cease  at  once  and  the  breast  should  be  kept  free 
from  secretion  by  use  of  the  breast-pump. 

As  soon  as  suppuration  occurs,  free  incision  is  indicated.  Occasionally 
pointing  occurs  late  and  appears  in  the  shape  of  a  slightly  softened  and  particu- 
larly tender  spot  in  the  swollen  gland.  Here  a  skin  incision,  followed  by  blunt 
boring  with  a  director  or  dressing  forceps,  will  finally  reach  the  suppurating 
focus.  Incisions  should  always  be  made  in  a  direction  radiating  from  the 
nipple,  in  order  to  avoid  cutting  across  the  lactiferous  ducts. 

In  case  retromammary  phlegmon  has  occurred  the  patient  must  be  anes- 
thetized and  the  suppurating  focus  behind  the  gland  sought  for  and  incised 
from  the  peripher\^  of  the  gland,  but  not  through  its  substance.  Any  openings 
already  made  in  the  breast  may  be  utihzed  in  the  search,  but  the  incision  which 
gives  free  access  to  the  retromammary  tissues  must  be  made  through  the  soft 
parts  of  the  chest  wall  in  a  position  to  give  the  readiest  access,  the  influence  of 
position  in  its  relation  to  free  drainage  being  also  borne  in  mind. 

Extensive  streptococcal  infection  vrith  multiple  small  foci  of  suppuration 
scattered  throughout  the  breast,  these  finally  coalescing  to  form  abscess  cavi- 
ties of  various  sizes,  is  sometimes  observed.  There  is  marked  constitutional 
disturbance  present,  and  often  great  prostration.  Ablation  of  the  entire  organ 
is  usually  necessar}',  in  these  cases,  in  order  to  arrest  the  systemic  infection. 
Sometimes  more  or  less  comparatively  healthy  skin  can  be  saved  to  hasten  the 
heahng  process. 

In  cases  of  multiple  mammary  fistulas  in  which,  through  neglect  early  in 
the  case,  multiple  foci  of  suppuration  have  formed  and  the  function  of  the  gland 
is  practically  destroyed  by  cicatricial  contraction  and  obliteration  of  the  lactif- 


THE    SOFT    PARTS    SURROUXDIXG    THE    CHEST  657 

croiis  ducts  and  acini,  and  in  wliich  the  fear  of  supervention  of  fibrous  carci- 
noma (scirrhus)  may  be  reasonably  entertaincMl,  extirpation  of  the  mamma  is 
to  be  resorted  to. 

The  treatment  of  lacteal  fistulas  consists  in  frecjuent  cauterizations  with 
nitrate  of  siher.  They  may  persist  because  of  the  presence  of  pus  and  infected 
granulations.     Tiiorough  curetting  is  to  be  employed  in  these  cases. 

Neuralgia  of  the  breast  (mastodynia)  probably  depends  upon  nerve 
pressure  in  the  course  of  chi-onic  interstitial  mastitis.  It  is  sometimes  difficult 
to  differentiate  between  neuralgia  of  the  breast  and  intercostal  neuralgia.  In 
severe  cases,  when  the  usual  general  measures  of  treatment  of  neuralgia  have 
failed,  amputation  ma}'  be  resorted  to. 

NONMALIGNANT  TUMORS  OF  THE  MAMMARY  GLAND 

Congenital    supernumerary     mammary    glands    (polymazia)     are 

analogous  to  the  lacteal  glands  of  mammals.  In  some  cases  two  or  more 
distinct  nipples  and  areolae  appear  on  a  single  gland.  Supernumerarv'  glands 
have  been  observed  in  the  axilla  and  on  the  outside  of  the  thigh  (R  o  b  e  r  t). 
This  abnormality  has  been  observed  in  the  male  sex  (Sanderson). 

Giantlike  growth  of  the  mammary  gland  occurs  at  the  period  of  adoles- 
cence. Both  mammae  are  usually  involved.  The  size  and  weight  of  the 
breasts  may  be  enormous.  Internal  and  external  use  of  iodin  are  recommended. 
Extirpation  may  be  resorted  to  in  extreme  cases. 

Adenomas. — These  constitute  a  common  form  of  tumor  of  the  breast. 
The}-  occur  principally  in  young  W'Omen  of  from  sixteen  to  twenty  years  of  age. 
They  are  situated  away  from  the  nipple  and  most  freciuently  near  the  lower 
edge  of  the  pect oralis  major  muscle.  These  tumors  rarely  exceed  an  egg  in  size, 
averaging  the  size  of  a  hazelnut.  They  are  of  a  consistency  harder  than  that  of 
the  breast ;  transitory-  forms  doubtless  exist  between  adenoma  and  fibroma 
(Billroth).  Adenomas  increase  in  size  temporarily  at  menstruation.  They 
are  of  slow  growth  and  are  situated  at  varying  depths  from  the  surface.  The 
treatment  consists  of  extirpation.  The  benign  character  of  the  growth,  when 
assured  by  microscopic  examination,  gives  immunity  from  recurrence.  On 
the  other  hand,  the  possibihties  of  carcinomatous  and  sarcomatous  develop- 
ment from  adenoma  and  adenofibroma  of  the  breast  are  such  as  to  justify  the 
remoA'al  of  the  tumor  in  every  instance. 

Fibromas  and  lipomas  of  the  mamma  are  rare.  The  variety  of  the 
latter  wliich  makes  its  appearance  behind  the  breast  (retromammary  Hpomas) 
should  be  mentioned.  Fibroma  may  develop  from  adenoma  or  independently; 
lipomas,  as  well  as  pure  fibromas.  are  seen  most  frequently  in  the  male 
breast.  Enchondromas  with  partial  ossification  have  been  reported 
(Cooper).     Atheromas  are  occasionally  seen  at  the  areola  and  nipple. 

Cysts  of  the  Mamma. — Cystic  dilatation  of  the  lacteal  ducts,  with  milky 
contents,  is  called  galactocele.  True  cysts,  multiple  or  single,  with  firm  walls 
(fibrocystoma),  or  in  conjunction  with  malignant  disease  (cystocarcinoma) 
are  observed.  Simple  cysts  with  clear  contents  are  not  uncommon.  Some- 
times the  contents  are  of  the  consistency  of  butter  (butter  cysts).  Deposit  of 
calcareous  and  other  salts  in  the  cysts  following  thickening  of  the  contents  of 
the  latter  constitutes  the  so-called  mammary  or  lacteal  calculi.  The  treat- 
ment of  benign  cvsts  is  puncture  and  subsequent  injection  of  tincture  of  iodin, 
43 


658  THE  SURGERY  OF  THE  THORAX 

If  they  persist,  they  should  be  removed.  Echinococcus  cysts  have  been 
observed. 

Malignant  Papillary  Dermatitis  (Paget's  Disease  of  the  Nipple).— 

This  consists  of  an  abnormal  development  of  the  interpapillary  processes, 
with  frecfuent  ol^literation  of  the  papillae.  It  affects  almost  exclusively  the 
nii)ple  and  surrounding  areola  of  women  in  the  cancerous  age,  and  is  usually 
followed,  in  the  course  of  two  or  three  years,  by  carcinoma  of  the  breast.  Its 
existence  may  extend  over  a  period  of  from  ten  to  twenty  years. 

Etiology. — The  disease  is  probably  cancerous  from  the  outset,  though  its 
malignanc}'  is  claimed  by  some  to  be  a  secondary  phenomenon  resulting  from 
constant  irritation  and  infection. 

Symptoms. — The  aj^pearances  are  those  of  a  moist  eczema.  The  nipple 
and  areola  present  a  raw,  granular  surface,  from  which  a  clear  viscid  fluid 
exudes.  The  edges  of  the  affected  area  are  well  defined;  in  old  cases  there  is 
considerable  infiltration.  Tingling  and  burning  are  present.  The  disease  may 
be  mistaken  for  ordinary  eczema  of  the  nipple.  The  latter,  however,  is  usually 
bilateral  and  lacks  the  sharply  defined  border  of  P  a  g  e  t  '  s  disease  as  well  as 
its  excessive  rawness.  Finally,  carcinomatous  nodules,  appearing  first  in  the 
lactiferous  ducts,  and  retraction  of  the  nipple,  occur  in  P  a  g  e  t '  s  disease. 

Treatment. — As  soon  as  the  diagnosis  is  assured,  the  entire  breast  is  to  be 
removed.  While  the  disease  may  last  for  a  long  time  wdthout  manifest  deteri- 
oration of  the  health,  it  will  sooner  or  later  prove  fatal  unless  operative  treat- 
ment is  resorted  to. 

MALIGNANT  TUMORS  OF  THE  BREAST 

These  are  far  more  frequent  than  benign  (82  out  of  100,  Bill- 
roth). 

Sarcomas. — These  are  of  rare  occurrence  compared  with  carcinomas  of  the 
breast.  The  presence  of  cystic  spaces  in  these  growths  has  given  rise  to  the 
term  "adenosarcoma."  Both  the  round-celled  and  the  spindle-celled  variety 
may  occur.  HyaUne  cartilage  and  even  bone  may  be  present.  The  round- 
celled  variety  grows  rapidly,  particularly  in  nursing  women.  The  spindle- 
celled  variety  grows  more  slowly.  The  disease  develops  between  the  twentieth 
and  the  thirtieth  year.  A  moderately  hard  and  painless  tumor  is  present. 
Secondar}^  lymphatic  glandular  involvement  occurs  late,  if  at  all.  When  the 
growth  breaks  clown  it  may  simulate  a  myxoma.  The  actual  occurrence  of  the 
latter  as  a  primary  form  of  the  disease  is  probably  extremely  rare,  though  a 
myxosarcoma  characterized  by  the  presence  of  striated  muscle  elements  is 
described  (Billroth). 

Melanosarcoma  is  the  rarest  of  all  mammary  tumors.  So-called  "  cystic 
sarcoma"  is  that  form  in  which  various  sized  cystic  spaces  develop,  these 
originating  probably  from  the  lactiferous  ducts  and  acini  in  the  immediate 
neighborhood  of  the  growth.  Sometimes  a  peculiar  leaf-like  proliferation  is 
present  in  one  of  the  cysts  (phylloid  cystic  sarcoma). 

Carcinoma  of  the  Mamma. — The  favorite  starting-point  of  cancer  of 
the  breast  is  in  the  acini;  exceptionally  it  occurs  in  the  ducts. 

Acinous  carcinoma  is  the  most  frequent  as  well  as  the  most  dangerous 
variety  of  mammary  cancer.  It  may  attack  any  portion  of  the  glandular 
structure,  but  it  affects  the  base  of  the  nipple  by  preference,  w^here  it  induces 


THE    SOFT    PARTS    SURROUXDIXG    THE    CHEST 


659 


early  retraction.     In  other  portions  of  the  gland,  a.s  involvement  of  the  skin 
takes  place,  retraction  of  the  latter  follows. 

The  growth  is  devoid  of  a  capsule  on  section  and  indefinitely  infiltrates  the 
entire  gland.  A  roughened,  leathery  sensation  is  imparted  as  the  growth  is 
incised  after  removal,  and  the  cut  .surfaces  present  the  appearance  of  an  unripe 
pear.  Sections  under  the  microscope  present  the  usual  appearances  of  alveolar 
spaces  filled  with  epithelium,  representing  the  columns  of  cells  characteristic  of 
carcinoma.  The  columns  are  arranged  in  the  lobules  of  the  gland  and  are 
embcddeil  in  tlense  fibrous  tissue.  Isolated  collections  of  cells  may  be  identi- 
fied well  beyond  the  apparent  limits  of  the  tumor.  The  proportion  of  fil^rous 
tissue  will  varv  greatly,  and  on  the  amount  of  this  tissue  present  will  depend 
the  solidity  of  the  growth.  In  the  variety  commonly  called  "  scirrhus  "  the 
fibrous  tis.-;ue  is  proportionately  abundant  (fibrous  carcinoma);  the  growth 
proceeds  slowly  and  contraction  of  the  gland  takes  place,  the  breast  being 
markedly  lessened  in  size.  Car- 
cinoma sometimes  arises  in  a 
supernumerary'  mammar}'  gland 
in  the  axilla. 

The  age  for  the  appearance 
of  acinous  carcinoma  of  the  breast 
is  between  the  fortieth  and  the 
fiftieth  year,  but  cases  of  patients 
between  thirty  and  forty  are  not 
uncommon.  It  is  rare  before 
thirty  and  after  seventy.  About 
one  per  cent  of  the  cases  occur  in 
the  male.  Blows,  overlactation, 
and  preexisting  mastitis,  particu- 
larly where  suppuration  has  oc- 
curred, may  be  considered  as 
taking  part  in  the  etiology. 
Rarely  both  breasts  are  concur- 
rently attacked. 

The  tumor  appears  insidious^ 
and  is  of  slow  growth,  except  dur- 
ing lactation,  when  it  grows  very  rapidly.  It  is  painless  at  first  and  rarely 
as.sumes  large  dimensions;  one  larger  than  the  fist  is  uncommon.  Infiltration 
occurs  early,  particularly  in  cases  in  which  the  fibrous  tissue  is  less  abundant. 
The  pectoral  fascia  and  pectoral  muscle  become  invaded,  the  channels  of  infec- 
tion being  the  lymphatic  vessels  which  pass  transversely  through  the  latter 
(H  e  i  d  e  n  h  a  i  n) . 

Lymphatic  glandular  infection  occurs  early;  this  and  the  lessening  in  size 
of  the  breast,  when  taken  in  conjunction  with  the  presence  of  a  tumor,  consti- 
tute the  most  valuable  diagnostic  signs  of  carcinoma  of  the  breast.  The  glands 
at  the  free  border  of  the  pectoralis  major  are  first  affected,  those  in  the  axiUa 
follow,  and  finally  those  above  the  cla^-icle  become  involved. 

The  skin  becomes  invaded,  causing  dimpling  or  puckering;  in  some  cases 
it  becomes  involved  in  the  shape  of  smaU  nodules  which  appear  like  duck-shot 
or  split  peas  in  the  substance  of  the  skin  (lenticular  skin  involvement,  see  Fig. 


Fig.  3S2. — SciRRHrs  Carcixoma  ix  the  Male  Breast. 
Four  years'   duration.     Inoperable.     Death  in  five 
months  with  lung  involvement.      (Patient  of  Dr.  Walter 
C.  Wood.) 


660 


THE  SURGERY  OF  THE  THORAX 


383).  Ulceration  is  preceded  b}'  a  brownish  or  a  bluish  appearance  of  the  skin. 
The  destructive  process  may  proceed  rapidly  and  deeply  in  some  cases  (Fig. 
383).  In  others  the  growth  proceeds  more  slowly  and  the  tumor  projects  above 
the  surface  in  the  shape  of  a  fungating  mass.  Pain  is  not  usually  a  prominent 
feature  until  the  later  stages  of  the  disease  are  reached,  and  some  patients  are 
free  from  it  altogether. 

Dissemination  takes  place,  as  a  rule,  following  the  lymphatic  glandular 


Fig.  38.3. — Advanced  Carcinoma  of  the  Breast. 
Showing  the  ulcerated  and  excavated  mammary  gland,  carcinomatous  infiltration  of  the  chest  wall 
and  of  the  deep  cervical  glands  of  both  sides,  lenticular  recurrences  in  the  skin,  and  extreme  edema  of  the 
lower  part  of  the  arm,  forearm,  and  hand  from  pressure  of  enlarged  glands  on  the  vessels  in  the  axilla. 


infection.  The  secondary  deposits  take  place  in  the  viscera,  especially  in  the 
lungs  and  liver,  but  they  may  take  place  in  any  organ.  Hydroperitoneum 
follows  secondary  deposits  in  the  liver,  pneumonia  and  pleurisy  those  in  the 
lungs  and  pleura,  mental  disturbances  and  coma  those  in  the  brain,  and  para- 
plegia, preceded  by  intense  suffering,  those  in  the  vertebral  column.  Deposits 
in  the  bones  are  sometimes  followed  by  spontaneous  fracture,  even  in  patients 
who  are  bed-ridden  (fracture  by  muscular  action).  Extensive  dissemination 
in  the  chest  wall  produces  extreme  induration  in  the  skin,  due  to  the  invasion 


THE    SOFT    PARTS    SUUUOUXDIXG    THE    CHEST  661 

of  the  lymphatics  of  this  structure;   the  latter  becomes  coarse  in  appearance 
and  hard  and  unyielding  (cancer  en  cuirasse). 

Progressive  emaciation  may  be  a  marked  and  early  feature ;  yet  in  a  certam 
proportion  of  the  cases  this  is  not  present  until  the  disease  is  ^vell  advanced. 
It  is  quite  common  for  the  patients  to  be  up  and  about  until  vcyx  late  in  the 

disease.  -    ,      i 

Lymphatic  edema  is  an  occasional  complication  of  cancer  ot  the  breast. 
It  is  due  to  the  pressure  of  infected  and  infiltrated  lymphatic  glands  and  secon- 
dary nodules  on  the  main  lymphatic  channels  in  the  apex  of  the  axilla,  or 
close  to  the  chest  wall  in  Mohrenheim's  fossa.  It  usually  involves  the  entire 
upper  extremity,  commencing,  as  a  rule,  in  the  neighborhood  of  the  shoulder 
and  even  involving  the  scapular  region.  The  connecti\e  tissue  is  infiltrated 
with  Ivmph  and  the  skin  is  firm,  bra^^•ny.  and  unyielding.  The  movements  of 
the  joints  are  interfered  with  and  the  limb  becomes  a  burden  to  the  patient 
(Fig.  383).  This  condition  is  usually  present  as  a  late  complication  in  the 
natiiral  historv  of  the  disease,  or  it  may  occur  in  late  operative  cases  irrespective 
of  whether  the  axillary  glands  have  been  removed  or  not.  It  may  simulate  the 
dissemination  in  the 'skin  kno^^-n  as  "cancer  en  cuirasse."  The  dropsical 
condition  of  the  arm  which  sometimes  follows  the  complete  operation  for  can- 
cer of  the  breast  and  which  is  due  to  cicatricial  interference  with  return  circu- 
lation should  not  be  mistaken  for  hTuphatic  edema.  In  the  former  the  skin 
will  pit  on  pressure,  while  in  the  latter  the  skin,  instead  of  pitting,  will  be  firm 
and  unyielding.  In  some  instances,  however,  the  condition  present  is  due  to  a 
combination  of  the  two  causes.  ^Yhen  pain  is  present,  it  is  due  to  pressure  on 
the  nerve-tmnks  bv  the  enlarged  glands,  or  to  secondary  growths. 

Carcinoma  of  the  ducts  occurs  just  before,  at,  or  after  the  menopause. 
The  growths  arise  in  the  dilated  ducts  or  "  mvolution  cysts"  so  frequently  pres- 
ent in  connection  with  atrophy  of  the  glandular  structure  due  to  the  climac- 
teric period.  The  dilated  ducts  or  cysts  are  occasionally  the  seats  of  new 
growths  such  as  papillomas  and  carcinomas.  Dilated  terminal  ducts,  and 
particularlv  the  ampullae  or  lacteal  sinuses,  are  the  favorite  locaUties  from 
which  these  sro^^i;hs  spring.  The  tumor  usually  occurs  singly,  is  of  slow 
growth,  varies'^in  size  from  an  English  walnut  to  a  goose-egg.  and  when  situated 
near  the  skin  presents  some  discoloration  suggestive  of  melanosarcoma.  The 
grovrth  lacks  the  hard  fibrous  feel  of  the  acinous  variety.  An  abundant  dis- 
charge of  dark  thin  fluid  from  the  nipple  is  usually  present.  The  lymphatic 
glands  are  rarely  infected,  dissemination  scarcely  ever  occurs,  and  recurrence 
following  the  removal  of  the  entire  breast  is  uncommon. 

The  prognosis  of  carcinoma  of  the  breast  is  always  unfavorable  if  the 
disease  is  allowed  to  pursue  its  natural. course.  The  average  duration  of  life 
AAithout  operation  is  twentv-two  months  (combined  statistics  of  Wini- 
warter. Fischer,  and"  E  s  m  a  r  c  h) .  Death  takes  place  from  ulcera- 
tion, sepsis,  hemorrhage,  and  exhaustion.  In  addition  to  the  breast  and  sub- 
pectoral and  axillary  lymphatic  glands,  the  retromammary-  fascia  and  fat, 
which  connect  by  numerous  lymphatic  channels  ^"ith  the  breast,  the  sheath 
and  substance  of  the  pectoralis  major  muscle,  the  intercostal  muscles,  perios- 
teum, ribs,  pleura,  and  lung  become  afi^ected.  Numerous  nodules  also  appear 
in  the  skin  of  the  thoracic  wall,  both  laterally  and  po.^teriorly.  Finally, 
secondary  deposits  occur  in  the  brain,  vertebral  colunm.  the  bones,  etc. 


662 


THE  SURGERY  OF  THE  THORAX 


Scirrhus  of  the  breast  in  males  has  been  noted  in  7  out  of  252  cases  of  the 
disease  (Billroth).  The  other  varieties  of  malignant  disease  are  also  rare 
here. 

The  treatment  of  malignant  tumors  of  the  mamma  consists  in  total 
removal  of  the  diseased  breast  and  of  all  neighboring  lymphatic  and  other  sus- 
piciously affected  structures.  The  condition  of  pregnancy  is  not  to  be  con- 
sidered a  contraindication  to  operation.  The  existence  of  lymphatic  involve- 
ment may  not  be  demonstrable  until  after  the  parts  are  exposed  by  turning 
back  a  flap  of  skin.  It  is  not  enough  simply  to  enucleate  the  individual  glands; 
the  entire  fatty  and  connective  tissue,  the  lymphatic  glandular  contents  of  the 
axillary  cavity,  the  loose  connective  tissue  between  the  latissimus  dorsi  and  the 


Fig.  384. — The  Radical  Operation  for  Carcinoma  or  the  Breast. 
The  lines  of  incision  for  amputation  of  the  breast  for  carcinoma.      1,1,  Elliptic  incision  surrounding 
the  breast;  2,  a.xillary  incision;    3,  incision  made  in  formation  of  flap  for  closing  the  gap  left  after  re- 
moval of  the  breast  (Warren) ;  4,  incision  for  removal  of  supraclavicular  glands.       (The  final  disposition 
of  flaps  A  and  B  is  shown  in  Fig.  389.) 


pectoralis  major  muscle,  the  glands  and  connective  tissue  lying  beneath  the 
latter  muscle  and  passing  from  it  to  the  mamma,  and,  finally,  except  in  the 
very  beginning  of  the  disease,  the  pectoralis  major  muscle,  and  if  necessary  the 
pectoralis  minor  as  well,  must  be  completely  extirpated.  These  structures 
should  all  be  removed  in  one  piece,  in  order  to  prevent  the  wound  from  becoming 
infected  by  the  division  of  tissue  invaded  by  the  disease  or  by  lymphatic  vessels 
containing  cancer  cells,  as  well  as  to  effect  complete  removal  of  all  cancerous 
tissue  (H  a  1  s  t  e  d) . 

The  Radical  Operation  for  Malignant  Disease  of  the  Breast  (Will  y 
Meyer;  Halsted;  Warren). — This  operation  aims  at  complete 
removal  of  the  gland,  the  immediately  underlying  muscular  parts,  and  the 


THE    SOFT    TARTS    SURROUNDING    THE    CHEST 


663 


glandular  and  fatty  contents  of  the  axilla.  The  incisions  will  necessarily  vary 
with  the  location  of  the  tumor.  In  the  majority  of  cases  the  following  method, 
developed  by  Willy  M  c  y  e  r ,  may  be  followed :  The  patient's  arm  is 
held  by  an  assistant  either  at  riglit  angles  with  the  body,  or  alongside  the 
head.  The  first  incision  commences  at  the  humeral  attachment  of  the  pector- 
alis  major,  and  is  carried  by  a  gentle  sweep  around  the  outer  border  of  the 
breast  and  finally  around  the  lower  border.  The  second  incision  commences 
at  the  middle  of  the  anterior  axillary  fold  and  is  carried  around  the  upper  and 
inner  margin  of  the  organ,  meeting  the  first  incision  at  its  terminal  point.  A 
flap  is  now  marked  out  on  the  outer  side  of  the  pectoral  region  by  dividing  the 
skin  above  the  middle  of  the  first  incision  and  carrsdng  the  cut  at  right  angles 
to  the  latter,  then  curving  it  until  it  becomes  parallel  to  the  level  of  the  lower 


Fig.  385. — The  Radical  Operation  for  Carcinoma  of  the  Breast. 
Dissection  of  the  integument  with   "undercutting  "  in  an  oblique  direction. 


margin  of  the  wound  and  finally  terminates  at  a  point  a  little  below  it 
(J.  Collins  Warren,  Fig.  384).  This  flap  is  to  be  afterward  utilized 
in  closing  the  gap.  In  case  of  lymphatic  involvement  in  the  cervical  region 
an  additional  incision  is  made,  which  is  commenced  at  the  middle  of  the 
second  incision  and  carried  across  the  clavicle  and  along  the  posterior  border  of 
the  sternomastoid. 

The  surrounding  skin  is  to  be  dissected  freely  in  all  directions,  including 
the  axilla,  so  as  to  remove  as  much  of  the  surrounding  fat  as  possible  with 
the  breast.  WTiere  the  incisions  lie  adjacent  to  the  latter,  the  method  of 
"undercutting"  in  an  oblique  direction  facilitates  this  step  of  the  operation. 
The  dissection  should  expose  the  cephalic  vein  and  the  clavicle;  the  fat 
overlying    the    pectoralis    major  muscle,   as    well    as    that  covering    in    the 


664 


THE  SURGERY  OF  THE  THORAX 


axilla  back  to  the  latissimiis  dorsi  and  nmning  doAMi  on  tho  lateral  chest  wall, 
should  be  allowed  to  remain  and  come  awa}-  with  the  breast,  jjlandular  struc- 
tures, and  fat  in  the  final  removal. 

The  lower  border  of  the  pectoralis  major  is  now  identified,  and  the  course 
of  the  cephalic  vein  as  it  lies  between  the  pectoral  muscle  and  the  deltoid 
determined.  The  forefinger  of  the  left  hand  of  the  operator  is  now  introduced 
from  below  so  as  to  isolate  the  humeral  insertion  of  the  pectoralis  major,  and 
the  latter  divided  close  to  the  bone  by  stout  blunt  scissors.  If  a  portion  of  the 
attachment  is  allowed  to  remain,  it  is  likely  to  slough.  The  muscle  is  now 
further  loosened  until  its  clavicular  attachments  are  reached.  An  assistant  now 
holds  the  muscle  and  breast  toward  the  median  line  while  the  operator  identi- 
fies the  pectoralis  minor  muscle  and  raises  it  on  his  fingers  and  divides  it  (Fig. 


Fig.  386. — The  Radical  Operation  for  Carcinoma  of  the  Breast. 
Exposure  and  division  of  the  humeral  attachment  of  the  pectoralis  major  muscle. 


386).  The  triangular  shaped  space  lying  behind  the  latter  muscle  and 
bounded  internally  and  posteriorly  by  the  chest  wall  (M  o  h  r  e  n  h  e  i  m)  is  thus 
exposed.  In  this  space  are  to  be  found  the  vessels  and  nerves  of  this 
region  and  the  glandular  structures  most  frec|uently  infected.  The  thin  layer 
of  fascia  overlying  the  vessels  is  now  divided.  The  vein  is  to  be  first  identified 
and  the  utmo.st  pains  taken  not  to  injure  this,  as  the  glandular  structures,  as 
well  as  the  fatty  and  loose  connective  tissues,  are  carefully  and  systematically 
dissected  (not  torn)  away.  The  arterj'  will  always  announce  its  presence  by  its 
pulsation,  and  the  nerv^e  cords  of  the  brachial  plexus,  from  their  larger  size  and 
hard  feel,  are  more  or  less  constantly  in  evidence.  But  the  vein  is  easily  ob- 
literated by  slight  pressure  in  the  course  of  the  manipulation  and  hence  may  be 
inadvertently  injured. 


THI-:  SOFT  I'AHTS  surrouxdint;  the  chest 


665 


The  entire  glandular  and  fatty  contents  of  the  axilla  and  Mohrenheini's 
fossa  are  dissected  loose  except  where  they  join  the  breast  and  pectoralis  major 
muscle.  In  this  dissection  the  latissimus  dorsi  muscle  is  exposed  before  the  fat 
layer  is  finally  cut  throufjh.  The  remaining;  attachments  of  the  pectoralis 
major  (clavicular,  sternal,  and  costal)  are  now  di\'idpd  in  succession,  the  entire 
mass  turned  in  an  outward  and  downward  direction,  and  the  removal  elTected 
by  completino;  the  section  on  the  outer  niaro;in  of  the  breast  through  the  re- 
maining attached  fat  layer.  The  vertical  incision  may  be  utilized  in  the  search 
for  infected  glands  in  the  clavicular  region  and  extend  up  on  the  neck  in  clear- 
ing out  any  suspicious  growths  in  the  supraclavicular  region. 

In  patients  whose  condition  will  not  permit  a  greatly  prolonged  operation 


Fig.  387. — The  Radical  Operation  for  Carcinoma  of  the  Breast. 
The  muscles  divided  and  the  mass  retracted,  exposing  the  a.xilla  and  giving  ready  access  to  Mohrenheim's 

fossa. 


it  is  better  to  accept  the  remote  risks  of  a  subseciuent  recurrence  from  cancerous 
infection  occurring  during  the  operation  than  to  court  the  immediate  dangers 
of  fatal  operative  shock.  Under  these  circumstances  the  operation  may  be 
considerably  shortened  by  first  removing  the  breast  and  then  the  pectoralis 
major  muscle.  The  pectoralis  minor  is  then  divided  (vide  supra)  so  as  to  give 
ready  access  to  Mohrenheim's  fossa  and  enable  the  operator  safely  to  clear 
this  and  the  axillary  region  of  suspicious  appearing  tissues  in  a  comparatively 
short  space  of  time.*     The  divided  pectoralis  minor  muscle  may  be  sutured  ^^'ith 

*  Theoretically  the  dissection  of  the  breast  from  tlie  muscle  is  objectionable  from 
the  fact  that  the  presumably  infected  lymph-channels  lying  behind  the  breast  are  opened 
up  This  is  no  more  true,  however,  than  in  the  case  of  the  removal  of  the  axillary  gland.s 
and  those  lying  on  the  edge  of  the  great  pectoral  muscles,  when  these  are  indubitably 
infected. 


666 


THE  SURGERY  OF  THE  THORAX 


catgut.  It  always  unites  and  resumes  its  function.  The  latter,  however,  is  not 
of  great  importance,  and  the  muscle  may  be  removed  as  a  routine  procedure 
along  with  the  pectoralis  major. 

Where  a  still  more  conservative  course  is  indicated,  and  in  exceptionally 
early  cases,  simple  removal  of  the  breast  and  extirpation  of  the  axillary  glands 
may  suffice.  In  this  class  of  cases  the  elliptic  incision  with  extension  of  the 
same  to  the  axilla  may  be  employed  (Fig.  390). 

In  closing  the  wound  the  axillary  flap  is  first  forced  well  up  in  position  by  a 
pad  of  sterilized  gauze  in  the  axilla,  so  as  to  elevate  the  fornix  of  the  latter  as 
much  as  possible  and  obliterate  the  "dead  space"  which  otherwise  would  exist, 
the  arm  being  brought  down  to  the  side  at  the  same  time.     In  aseptic  cases  no 


Fig.  388. — The  Radical  Operation  for  Carcinoma  or  the  Breast. 
Exposure  and  division  of  the  pectoralis  minor  muscle. 


drainage  is  recpired.  The  thoracic  wound  is  closed  as  completely  as  possible. 
If  a  gap  remains,  this  may  be  filled  with  Thiersch  transplantation  strips 
immediately,  or  when  granulation  is  well  under  way.  Where  Warren's 
flap  is  employed  excellent  approximation  can  usually  be  obtained.  It  should 
be  placed  in  position  and  sutured  with  as  little  tension  as  possible,  in  order  to 
avoid  endangering  its  vitality  (Fig.  389).  Failure  to  observe  this  precaution 
not  infrequently  leads  to  gangrene. 

In  Halsted's  original  method  the  steps  of  the  operation  are  mainly  in  the 
reverse  order  from  those  just  detailed.  These  include  the  following:  (1)  The 
reflection  of  a  triangular  shaped  skin  flap  (Fig.  391) .  The  fat  layer  at  the  site  of 
this  flap  is  dissected  back  to  the  lower  margin  of  the  pectoralis  major  muscle. 
(2)  The  pectoralis  major  muscle  is  severed  first  at  its  costal  and  then  at  its  clavic- 


THE    SOFT    TARTS    SrURorXDlXO    THE    CHEST 


667 


\ilar  insertions,  and  finally  at  its  luim(>ral  attaclnnent.     (3)  The  whole  mass  thus 
far  loosonc^l  is  strii->pe(i  from  the  thorax  and  from  the  peetoralis  minor  muscle. 


Fig.  3S9. — The  Radical  Operatiox  for  Carcixoma  of  the  Breast. 
Mode  of  closing  the  wound  when  Warren's  flap  is  employed. 


FlQ. 


390. — Elliptic    Incision    for    Simple    Removal    of  the    Breast    and    Extirpation  of    the 

Axillary    Glands. 


(4)  The  pectoralis  minor  muscle  is  cleared  and  divided  across  near  its  middle, 
and  the  tissues  near  its  coracoid  insertion,  together  with  the  loose  connective 
tissue  lying  under  the  muscle  itself,  are  dissected  away.     (5)  The  subcla\dan 


668  THE  SURGERY  OF  THE  THORAX 

vein  is  exposed  at  its  highest  point,  and  the  contents  of  the  axilla,  including  the 
loose  tissue  above  the  vessels  and  about  the  brachial  plexus  of  nerves,  carefully 
dissected  (not  pulled)  away.  After  the  vessels  and  nerves  are  cleared  the  lateral 
wall  of  the  thorax  is  stripped,  and  finally  the  posterior  wall  of  the  axilla.     The 


Fig.   391. — Halsted's  Radical  Operation  for  Carcinoma  of  the  Breast. 
Showing  the  hnes  of  incision  and  the  reflection  of  the  flap. 


Fig.  392. — Halsted's  Radical  Operation  for  Carcinoma  of  the  Breast. 
The  mass  turned  back. 

mass  is  now  held  only  at  the  posterior  line  of  incision  (Fig.  392).     This  is 
severed  by  a  few  strokes  of  the  knife. 

In  closing  the  wound  it  is  important  to  apply  the  triangular  shaped  flap 
closely  to-  the  fornix  of  the  axilla  by  a  mass  of  gauze  crowded  well  up  in  the 
axillary  space.      This  obliterates  the  dead  space  and  lessens  the  amount  of 


THK    SOFT    PARTS    SURROUXDIXC    THE    CHEST  669 

cicatricial  tissue  I'ornunl,  thcrehy  ix-ducin"!;  to  a  iniiiinmm  the  sii])sequcnt  dis- 
ability of  the  arm. 

When  the  subcla\iau  artery  and  vein  ])ass  tln-ough  the  glandular  growths 
and  are  intimately  attached  thereto,  they  have  been  extirpated  with  the  latter 
between  two  ligatures.  This  condition  is  rarely  encountered,  however,  for  the 
reason  that  it  is  present  only  in  those  advanced  cases  in  which  operation  should 
not  be  undertaken.  In  cases  otlierwise  favorable  for  oj^eration  the  lymphatic 
and  fatty  structures  in  the  axilla  can  usually  be  dissected  from  the  blood-\-essels 
and  nerves.  Glandular  in^•olvement  in  the  supraclavicular  region  renders  the 
prognosis  unfavorable. 

Whatever  method  of  operation  is  adopted  the  skin  incisions  must  be  made 
wide  of  the  diseased  area  and  so  placed  as  to  afford  ready  access  to  the  entire 
mammary  region,  and  b}'  extension  to  the  axillary,  infraclavicular,  and  sub- 
pectoral regions  as  well.  In  making  the  deeper  dissections  the  blood-supply 
should  be  taken  into  account  and  the  vessels  which  supply  the  gland  divided 
and  clamped  early,  in  order  to  avoid  constant  repetition  of  this  portion  of  the 
technic.  Bleeding  points  are  to  be  secured  at  once ;  if  the  clamp  forceps  become 
so  numerous  as  to  be  in  the  way,  the  vessels  are  to  be  ligated  with  catgut  before 
completion  of  the  operation.  Hot  towels  applied  for  a  few  seconds  will  arrest 
the  parenchymatous  oozing.  Complete  hemostasis  must  be  assured  before 
the  wound  is  closed. 

Strictly  aseptic  conditions  obviate  the  necessity  for  drainage-tubes.  Copious 
gauze  dressings  are  to  be  applied,  covered  by  sterilized  cotton,  and  held  in  place 
by  a  snugly  fitting  chest  binder  with  hollow  places  cut  under  the  arms.  The 
arm  is  wrapped  in  sterilized  cotton  and  bandaged.  For  the  first  few  days  the 
arm  is  placed  over  the  chest  and  there  secured  by  a  few  turns  of  a  broad  roller 
bandage.  If  all  goes  well,  the  dressings  are  not  disturbed  for  a  week,  at  the 
end  of  which  time  the  sutures  are  removed. 

The  prognosis  after  operation  will  vary  with  the  stage  of  the  disease  at 
which  interference  is  undertaken.  Death  resulting  from  the  operation  itself 
is  rare  in  ordinary  uncomplicated  cases.  Before  the  introduction  of  aseptic 
methods  the  mortality  was  25  per  cent.  Healing  takes  place  in  about  fourteen 
days.  Recurrence  of  the  disease  is  to  be  expected  in  late  cases  within  the  first 
three  months.  The  immunity  from  regional  recurrence,  or  the  appearance  of 
the  disease  in  remote  parts  of  the  body  will  be  in  direct  proportion  to  the 
advances  made  by  the  disease  at  the  time  of  the  operation,  and  the  complete- 
ness of  the  latter.  Prompt  recurrence  may  follow  an  incomplete  operation, 
even  when  undertaken  in  the  very  earliest  stages,  while  a  complete  operation 
may  afford  comparative  or  complete  immunity  when  the  disease  is  well  ad- 
vanced. In  a  recurrence  the  lymphatic  glands  are  usually  involved  in  advance 
of  the  cicatrix.  Next  in  frequency  the  skin  is  attacked  in  the  shape  of  scattered 
lenticular  indurations.  These  should  be  promptly  removed.  Keloid  develop- 
ment in  the  cicatrix,  or  at  the  site  of  suture  punctures,  is  to  be  looked  on  with 
suspicion.  If  a  year  elapses  without  recurrence,  the  prognosis  is  thereafter 
favorable. 

The  movements  of  the  arm  are  generally  more  or  less  interfered  ^nth  at  first, 
particularly  that  of  abduction.  If  this  interference  is  due  to  shortening  of  the 
cicatrix  at  the  site  of  the  incision  which  crosses  the  front  of  the  axilla,  a  plastic 
operation  may  be  indicated.     Usuall}-,  however,  this  part  of  the  incision  can  be 


670 


THE  SURGERY  OF  THE  THORAX 


Clinked  sufficiently  in  an  upward  direction  to  avoid  this  sequel.  Early  and  per- 
sistent passive  and  active  movements  will  usually  lead  to  restoration  of  function 
in  time.  All  tendencies  toward  recurrence  should  be  promptly  met  b}'  further 
operations,  though  the  prognosis  is  graver  under  these  circumstances.  The 
average  duration  of  life  after  operation,  in  cases  in  which  recurrence  takes 
place,  is  thirty-four  months,  a  distinct  gain  of  at  least  a  year  over  cases  which 
are  permitted  to  pursue  their  natural  course.  These  figures  are  taken  from 
the  combined  statistics  of  Winiwarter,  Fischer,  and  E  s  m  a  r  c  h  . 
They  w^ere  compiled  by  these  authors  before  the  introduction  of  the  more  radical 
procedures  now  employed.  While  it  is  true  that  slightly  greater  risks  are  taken 
with  the  latter,  more  benefit  in  the  way  of  greater  immunity  from  recurrence 
is  derived  in  cases  that  recover. 

In  cases  of  inoperable  carcinoma  of  the  breast  the  treatment  consists  of 
efforts  to  restrict  the  septic  processes  by  antiseptic  applications,  and  possibly 
of  the  removal  of  broken-dowTi  portions  by  the  sharp  spoon.     Opium,  adminis- 


FiG.  393. — Line  of  Incision  for  the  Removal  of  Nonmalignant  Tumor  of  the  Inferior  Quadrant 

OF  THE  Breast. 

tered  both  internally  and  locally  (acjueous  extract  of  opium,  1  part,  simple 
ointment,  20  parts),  is  to  be  used  to  allay  pain.  The  application  of  styptics 
may  be  necessary  to  arrest  hemorrhage. 

Nonmalignant  growths  may  be  isolated  and  removed  as  elsewhere,  need- 
less sacrifice  of  mammary  tissue  and  mutilation  being  avoided.  In  cases  of 
fibromas  which,  as  a  rule,  are  situated  on  the  outlying  portion  of  the  breast,  the 
skin  incision  should  be  made  in  the  sulcus  between  the  lower  margin  of  the 
breast  and  the  skin  of  the  chest  wall,  the  parts  lifted,  and  the  tumor  removed 
from  that  direction  (Fig.  393).  The  precise  location  of  this  incision  will  neces- 
sarily vary  with  the  location  of  the  tumor. 


THE  BONY  CHEST  WALLS 

Fractures    of    the  Ribs. — Fractures  of  the  ribs  are  very  rarely  seen   in 
children,  owing  to  the  great  elasticity  of  the  chest  walls.     Later  in  life  the  boii}^ 


THE    BOXY    CHEST    WALLS  671 

portions  of  the  ribs  become  more  brittle,  and  the  costal  cartilages  also  lose 
their  elasticity  by  partial  ossification.  The  false  ribs  are  much  less  liable  to 
fracture  tlian  the  true  ribs,  owing  to  their  cartilaginous  connections,  until  late 
in  life,  when  the  latter  undergo  calcification  and  give  way  upon  the  application 
of  greater  force. 

The  repair  of  fractures  involving  the  cartilages  takes  place  as  follows:  The 
perichondrium  furnishes  a  ring  of  Ijone  which  surrounds  in  a  ferulelike  manner 
the  ends  of  the  fragments.     The  fractured  surfaces  do  not  unite. 

According  to  G  u  r  1  t  ,  fractures  of  the  ribs  represent  17  per  cent  of  all  the 
fractures  in  the  body.  The  form  of  fracture  varies  with  the  \Tilnerating  force. 
Splintered  fractures  result  from  direct  force,  such  as  that  inflicted  by  small  mis- 
siles, while  transverse  fractures  follow  indirect  force,  such  as  forced  compression 
of  the  chest  in  an  anteroposterior  direction,  when  several  ribs  may  be  broken 
simultaneously;  these  usuall}^  give  way  in  the  axillar\'  line.  The  eleventh  and 
twelfth  ribs  are  rarely  broken,  on  account  of  their  loose  connections,  and  the  first 
rib  escapes  because  of  its  short  arch  and  broad  transverse  section.  The  remain- 
ing ribs  (second  to  eighth)  suffer  the  most  frequently.  The  ribs  on  one  side  give 
way  only  with  the  lateral  application  of  the  force.  When  this  is  appHed  in  an 
anteroposterior  direction  so  as  to  force  the  sternum  toward  the  spinal  column 
the  ribs  on  both  sides  of  the  chest  may  A'ield.  The  fragments  may  be  displaced 
inward,  rarely  outward.  Usually,  however,  owing  to  the  elasticity  of  the  chest 
wall,  the  fragments  resume  their  normal  position. 

Incomplete  fracture  is  rather  commonly  observed,  the  inner  lamella  being 
the  portion  bent,  wliile  the  external  lamella  is  broken.  This  may  occur  in 
3"oung  and  middle-aged  persons  from  elasticity  of  the  chest  walls,  and  in  the 
aged  from  senile  atrophj-. 

Dislocations  of  the  costal  cartilages  sometimes  occur  after  the  application  of 
comparatively  shght  force,  on  account  of  the  arrangement  of  the  articulations 
of  these  with  the  ribs,  this  amounting  in  many  instances  to  a  simple  cleft  sur- 
rounded by  a  strijD  of  synovial  membrane. 

Complications. — Compound  fractures  are  rare.  In  gunshot  fractures, 
where  these  are  penetrating  or  perforating,  the  skin  injury-  as  well  as  the  fracture 
is  unimportant  compared  with  the  damage  done  to  the  pleura,  lung,  etc.  Severe 
contusions,  or  even  lacerations  of  the  lung  substance  may  occur  in  the  young, 
without  fracture  of  the  rib,  the  rupture  of  smaU  capillaries  giAlng  rise  to  hem- 
orrhage in  the  alveoli  and  small  bronchi.  According  to  K  6  n  i  g  ,  this  injury 
is  more  likely  to  occur  if  the  glottis  is  closed  when  the  force  is  applied  to  the 
chest  waU.  In  laceration  of  the  lung  by  fragments  of  a  broken  rib  these  are 
forced  through  both  layers  of  the  pleura.  Here  hemorrhage  may  occur  into 
the  cavit}'  of  the  pleura  (hemothorax)  and  into  the  alveoli  and  smaller  bronchial 
tubes  as  well.  It  is  removed  from  the  latter  situation  by  coughing.  Its 
presence  in  the  pleural  cavity  will  be  announced  by  a  progressively  ascending 
line  of  dullness.  During  expiration  air  is  forced  from  the  alveoli  and  broncliial 
tubes  into  the  pleural  cavity  (pneumothorax) ;  a  highly  tympanitic  percussion 
note  is  present  above  the  area  of  dullness.  As  the  canity  of  the  pleura  is  filled 
with  air  and  blood,  the  lung  is  compressed  and  the  hemorrhage  is  arrested.  Air 
that  has  passed  along  the  pulmonary  tract  is  not  so  likely  to  be  followed  by 
suppuration  of  the  contents  of  the  pleural  cavity  as  that  which  enters  through 
a  wound  in  the  chest  waU.     In  the  former  instance  the  air  is  more  or  less  freed 


672  THE  SURGERY  OF  THE  THORAX 

from  irritating  matters  in  its  passage.  The  bloocl  in  the  pleural  cavity  is  gen- 
erally absorbed  readily;  the  wound  in  the  lung  heals  usually  by  first  intention, 
precisely  as  an  aseptic  wound  of  the  external  skin  does  when  its  edges  are  held  in 
close  apposition. 

If  the  dyspnea  becomes  urgent,  the  contents  of  the  pleural  cavity  may 
be  removed  by  means  of  the  aspirator.  This  should  be  delayed  sufficiently 
long  to  permit  perfect  hemostasis  at  the  site  of  the  wound  of  the  lung. 

The  intercostal  arteries  may  be  injured  in  cases  of  fracture  of  the  rib,  l^ut 
the  hemorrhage  from  this  source  is  not,  as  a  rule,  serious.  The  long  thoracic 
arter\-  may  be  injured  by  a  fracture  of  the  rib  and  may  require  ligation.  The 
internal  mammary  is  more  liable  to  be  injured  by  stab  wounds. 

Emphysema  of  the  connective  tissue  occasionally  occurs  when  fracture  of 
a  rib  and  injury  of  the  lung  occur  simultaneously,  the  pleural  cavity  being  first 
filled  with  air,  which  subsequently  finds  its  way  into  the  loose  connective  tissue 
around  the  ribs,  finally  reaching  the  subcutaneous  connective  tissue.  The 
accumulation  in  the  pleural  cavity,  by  compressing  the  lung,  usually  arrests 
quite  promptly  the  escajDc  of  air,  except  in  cases  in  which  this  is  prevented  by 
adhesions  between  the  costal  and  the  pulmonar}'  surface  of  the  pleura.  Unless 
arrested  the  emphysema  may  reach  the  neck  and  head,  and  finally  invade  the 
entire  subcutaneous  connective  tissue  of  the  body  and  the  connective  tissue  of 
the  lungs  and  mediastinal  space,  death  taking  place  from  mechanic  obstruc- 
tion of  the  circulation  and  dyspnea. 

Diagnosis. — Displacement  of  fragments  is  comparatively  rare.  Localized 
pain  is  a  constant  symptom.  Cough  and  bloody  expectoration  may  occur  in 
contusion  of  the  lung  with  or  without  fracture  of  the  ribs.  Palpation  may 
disclose  crepitation,  but  this  sign  is  more  frequently  obtained  by  auscultation. 
Tenderness  at  the  injured  point  may  be  elicited  by  pressure  on  the  sternum. 
Deep  inspiration  usually  increases  the  pain,  though  this  is  not  always  the  case. 
When  the  pleura  is  injured,  pleuritic  friction  sounds  may  be  heard  on  ausculta- 
tion. This  may  occur  in  only  partial  fracture,  the  inner  surface  of  the  rib  giving 
way,  while  the  outer  surface  remains  intact. 

Treatment. — Simple  fracture  of  the  ribs  is  to  be  treated  by  opiates  to 
relieve  the  pain,  and  by  strapping  the  corresponding  half  of  the  chest  by  means 
of  adhesive  plaster.  Marked  outward  displacement  of  the  fragments  is  to  be 
corrected  by  pressure  from  without.  Permanent  inward  displacement  is  rare; 
it  may  be  corrected  by  passing  a  sharp  hook  behind  the  fragments  and  making 
traction.  If  suppurative  changes  take  place  in  the  contents  of  the  pleural 
cavity  (pyothorax,  or  traumatic  empyema),  free  incision,  with,  perhaps, 
resection  of  a  rib  to  facilitate  draining,  should  be  performed.  Compression  of 
the  chest  wall  by  means  of  an  elastic  bandage  is  useful  in  cases  of  slight 
emphysema.  Punctures  and  incisions  are  admissible  only  when  a  slight  area 
of  emphysema  exists. 

Caries  of  the  Ribs. — A  number  of  affections  w^ere  formerly  included 
under  this  name.  At  the  present  time  these  are  classified  as  (1)  granular 
myelitis  of  tuberculous  origin;  (2)  traumatic  suppurative  periostitis  occurring 
in  connection  with  compound  fractures  (gunshot  injuries,  etc.);  (3)  suppurative 
periostitis  from  phlegmonous  inflammation  of  the  soft  parts  of  the  chest  wall; 
(4)  syphilitic  disease  of  the  ribs;  (5)  typhoid  infection  of  the  ribs. 

Granular  Myelitis. — Contrary  to  the  usual  rule  governing  this  affection, 


THE    BOXY    CHEST   "WALLS  673 

tuberculous  inflammation  of  the  l)onc  in  this  region  is  less  frequently  observed 
in  children  than  in  adults.  It  nia}'  appear  even  in  advanced  age.  A  cold 
abscess  gradually  develops,  sometimes  behind  the  mamma;  the  resulting  fluc- 
tuating tumor  may  resemble  cystic  sarcoma  of  that  organ.  In  other  cases  it 
passes  in  the  direction  of  the  pleura  (subcostal  abscess)  and  may  be  mistaken 
for  empyema.  It  may  invade  the  pleural  cavity,  in  which  case  there  may  be 
caries  of  the  rib,  complicated  with  .suppurative  pleuritis. 

The  favorite  seat  of  this  affection  is  the  lateral  aspect  of  the  chest  wall, 
though  the  posterior  and  anterior  portions  may  ])e  attacked.  The  middle  ribs 
are  most  frecjuently  afi"ected.  Granular  perichondritis  of  the  costal  cartilages 
leading  to  extensive  destruction  is  sometimes  observed.  It  occurs  more  fre- 
Cjuently  in  children  than  in  adults. 

Suppurative  periostitis  may  follow  infection  of  wounds  of  the  ribs  and  soft 
parts,  and  may  result  as  well  from  phlegmonous  inflammation  of  nontraumatic 
origin.  The  probe  may  .detect  bare  bone  when  fistulous  openings  exist.  The 
inflammation  is  usually  only  superficial  and  rapidly  disappears  after  free  incision, 
scraping  of  the  rib  with  the  sharp  spoon,  and  antiseptic  treatment. 

Syphilitic  disease  of  the  ribs  is  sometimes  observed.  A  gununa  develops 
first.  This  softens  and  breaks  down.  It  is  difficult,  in  man}^  cases,  to  differen- 
tiate at  this  stage  between  this  condition  and  true  caries.  The  history-  of  the 
case  must  be  taken  into  account,  and  other  manifestations  of  syphilis  sought 
for.  Antisyphilitic  measures  may  here  be  employed  for  both  diagnostic  and 
therapeutic  purposes. 

Typhoid  infection  of  the  ribs  has  been  observed.  The  resulting  lesion 
may  assume  the  characters  of  osteitis  and  periosteitis,  or  osteomyehtis. 

Treatment  of  Caries  of  the  Ribs. — Prompt  resection  of  the  affected  bone 
is  indicated,  not  only  with  the  hope  of  preventing  general  tuberculous  infection, 
but  in  order  to  avoid  the  development  of  suppurative  pleuritis.  Granular 
perichondritis  is  best  treated  by  exposing  the  affected  area  and  gouging  away 
the  diseased  cartilage.  Healing  by  organization  of  a  blood-clot  under  a  dressing 
of  oiled  silk  or  iiibber  tissue  (S  c  h  e  d  e)  should  be  obtained,  if  possible.  Heal- 
ing by  granulation  is  ver^,^  tedious  and  frequently  fails  altogether,  the  diseased 
condition  constantly  extending,  in  spite  of  every  effort. 

Abscess  of  the  chest  walls  originating  in  perforation  of  a  sup= 
purating  cavity  of  the  lung  is  sometimes  obserA-ed.  It  is  most  fre- 
cpently  situated  on  the  upper  portion  of  the  anterior  surface  of  the  thorax, 
usually  at  the  first  or  second  intercostal  space.  Adhesions  generally  occur 
before  perforation  takes  place;  the  fistulous  opening  leads  directly  into  the 
lung  cavit}'.  As  the  latter  usually  conmnunicates  with  a  bronchial  tube,  air 
may  escape  with  the  pus. 

Billroth  has  described  a  peculiar  suppurative  process  developing 
between  the  costal  pleura  and  the  bony  chest  wall  (suppurative  peripleuritis). 
Its  origin  is  imknoA^m  and  it  is  verA'  likely  to  be  confounded  with  empyema. 

Neuralgia  of  the  intercostal  nerves  belongs  to  the  domain  of  general 
medicine.  X  u  s  s  b  a  u  m  ,  however,  once  cured  an  intractable  case  of  this 
kind  by  nerve  stretching. 

Tumors  of  the  Ribs  and  Thoracic  Region. — The  costal  cartilages  are 
almost  absolutely  exempt  from  neoplasms. 

Chondroma  of  the  Ribs. — Tliis  is  of  frequent  occurrence  in  otheiT\'ise 
44 


674  THE  SURGERY  OF  THE  THORAX 

healthy  persons.  It  is  observed  between  the  twentieth  and  the  fortieth  year. 
It  springs  from  the  bony  and  not  from  the  cartilaginous  portions  of  the  ribs, 
is  of  slow  growth  and  painless.  Early  successive  invasion  of  more  than  one  rib 
is  the  rule.  The  direction  of  the  growth  is  generally  outward  and  rarely 
toward  the  pleural  surface.  In  larger  growths  the  pressure  on  the  skin  and 
friction  of  the  clothing  may  lead  to  ulceration,  and  death  may  result  from 
breaking  down  of  the  tumor  and  consequent  septicemia.  Myxomatous  de- 
generation may  also  occur  and  even  transition  to  sarcoma  take  place  (C  . 
H  u  e  t  e  r) .  Secondary  nodules  are  liable  to  occur  in  the  lungs  or  other 
internal  organs,  these  having  an  embolic  origin. 

In  view  of  these  unfavorable  tendencies  in  advanced  chondroma  the  treat- 
ment should  consist  in  early  extirpation.  Owing  to  the  absence  of  pain  as  a 
s^miptom,  surgical  aid  is  not  sought,  as  a  rule,  until  the  growth  has  attained  a 
large  size.  In  early  operations  the  growth  can  be  removed  without  opening 
the  pleural  cavity.  Late  interference,  when  undertaken  at  all,  necessitates 
most  desperate  operative  attempts. 

Sarcoma. ^ — This  attacks  the  ribs  much  more  rarely  than  chondroma. 
Angiosarcoma  is  the  usual  variety.  It  may  occur  late  in  life,  in  w^hich  case 
operation  is  scarcely  "justifiable.  When  the  heads  or  necks  of  the  ribs  are 
attacked,  the  disease  may  invade  the  intervertebral  foramina  and  compress  the 
cord. 

Carcinoma. — This  is  found  only  as  a  seeondar}^  growth  in  cases  of  carci- 
noma of  the  manmia. 

THE  STERNUM 

Fracture. — Splintered  fractures  may  occur  in  gunshot  injuries  or  from 
other  projectiles.  Transverse  fracture  may  follow  the  application  of  great 
force,  the  fragments  becoming  considerably  displaced.  In  this  class  of  injuries 
the  manubrium  is  held  securely  in  position  by  its  attachments  to  the  first  rib, 
while  the  body  of  the  sternum  is  displaced.  This  separation  of  the  body  of  the 
sternum  from  the  manubrium  has  been  called  a  dislocation;  this  name,  how- 
ever, is  incorrectly  applied.  The  injury  partakes  of  the  character  of  a  dias- 
tasis. The  same  may  be  said  of  separation  of  the  ensiform  appendix.  Frac- 
ture of  the  sternum  may  occur  in  connection  with  dislocation  of  the  upper 
dorsal  vertebrae. 

The  treatment  consists  in  elevating  the  depressed  portion  by  manipulation 
with  the  fingers.  This  failing,  it  may  be  lifted  into  position  by  means  of  a 
strong  hook.  Serious  functional  results  are  not  common  even  if  the  displace- 
ment is  not  corrected. 

Dangerous  traumatic  suppuration  following  ginishot  wounds  may  occur 
behind  the  sternum  and  invade  the  anterior  mediastinum  (anterior  medias- 
tinitis).  The  suppurative  process  may  extend  to  the  pleura  and  pericar- 
dium. The  treatment  of  anterior  mediastinitis,  both  when  it  results  from  the 
cause  just  mentioned  and  when  it  arises  from  suppurative  processes  originating 
in  the  lateral  cervical  region  and  extending  beneath  the  sternothyroid  muscles 
into  the  anterior  mediastinal  space,  is  trephining  the  sternum.  The  opera- 
tion, however,  is  not  performed  with  a  trephine  but  with  a  chisel. 

Syphilitic  caries  of  the  sternum  is  relatively  frequent.  Tuberculous 
caries    is  not  rare  and  occurs  by  preference  at  the  manubrium  and  upper 


THE    BONY    CHEST    WALLS  675 

portion  of  the  body  of  the  sternum.  Thorough  division  of  all  fistulous  tracts, 
scraping  slwhx  all  diseased  tissue  with  the  sharp  spoon,  trimming  away 
the  infected  lining  of  the  sinuses,  and  thorough  antisepsis,  will  prevent  septic 
conditions  in  the  anterior  mediastinum  and  may  result  in  cure.  Typic  re- 
section of  the  diseased  portion  of  the  sternum  has  been  successfully  performed 
in  recent  times,  owing  to  the  advantages  of  asepsis  and  antisepsis.  In  syphil- 
itic cases  antisyphilitic  treatment  should  supplement  the  operative  procedure. 

Sarcoma  of  the  sternum  is  observed.  It  develops  as  true  sarcoma  of 
the  bone  or  originates  in  the  connective  tissue  of  the  anterior  mediastinal  space. 
A  large  soft  tumor  is  formed,  which  gradually  destroys  the  sternum  and  finally 
invades  the  skin.  Destruction  of  the  upper  portion  of  the  sternum  also  attends 
the  development  of  aneurism  of  the  ascending  portion  of  the  arch  of  the  aorta. 
Chondroma  of  the  sternum  is  comparatively  rare.  Resection  of  the  entire 
sterniim  has  been  successfully  performed  for  osteoid  chondroma  (Konig). 
The  justifiability  of  operative  interference  in  sarcoma  of  the  sternum  must  rest 
on  the  possiliilities  of  removal  of  the  entire  disease. 

Congenital  fissure  of  the  sternum  is  mentioned  as  a  curiosity.  The 
physiologic  action  of  the  heart  can  usually  be  studied  through  the  skin  which 
fills  in  the  hiatus. 

EFFUSIONS  INTO  THE  PLEURAL  CAVITY  AND  THEIR  SURGICAL 

TREATMENT 

Effusions  into  the  pleural  cavity  may  result  from  the  lodgment  of  foreign 
bodies,  from  injury  to  the  pleural  membrane  by  a  fractured  rib,  from  the  pre- 
sence of  malignant  growths,  from  circulatory  disturbances  (hydro thorax),  and 
from  simple  pleuritis. 

Hydrothorax  is  a  simple  noninfiammatory  water}-  effusion  into  the  pleural 
cavity  and  is  due  to  circulatory  disturbances  following  diseases  of  the  heart  and 
kidney,  and  to  changes  in  the  blood  itself.  The  accumulation  usually  takes 
place  in  both  sides  of  the  chest  and  may  threaten  life  by  suffocation.  It  may 
be  removed  by  aspiration. 

In  simple  pleuritis  with  effusion,  if  two-thirds  or  more  of  the  cavity  of  the 
pleura  is  occupied  by  the  serous  exudation,  the  pressure  of  the  accumulated 
fluid  will  be  such  as  to  prevent  the  absorbent  vessels  from  disposing  of  the  fluid. 
Here  a  portion  or  all  of  the  fluid  may  be  withdrawm  by  simple  aspiration. 

Septic  and  tuberculous  inflammation  of  the  pleura  may  follow  similar 
affections  of  the  pulmonary  tissues. 

Empyema. — A  suppurative  pleuritis  is  knowm  as  empyema.  Staphylo- 
cocci and  streptococci  are  usually  found  in  the  pus.  Ordinar}-  catarrhal  bron- 
chitis may  furnish  the  microorganisms  which,  through  involvement  of  some  of 
the  alveoli,  may  lead  to  infection  of  the  pleura  and  consecjuent  suppurative 
pleuritis.  A  serous  effusion  from  idiopathic  (primary)  pleuritis  may  become 
infected  by  the  pneuococcums  of  a  coincident  pneumonia.  Or,  bacterial  infec- 
tion maj^  occur  in  a  carelessly  performed  exploratory'  puncture,  and  empyema 
result.  Gangrene  of  the  pleura  has  been  observed  in  connection  with  general 
pyemia. 

Two  or  more  separate  ca'sities  may  be  present  at  the  same  time  (encysted 
pleuritic  effusion  and  encysted  empyema).  The  fluid  in  one  ca\aty  may 
remain  serous  and  be  absorbed,  while  that  in  the  other  mav  become  infected  and 


676  THE  SURGERY  OF  THE  THORAX 

undergo  suppuration.  These  cavities  may  be  separated  from  each  other  by 
adhesions  between  the  visceral  and  the  costal  reflections  of  the  pleura. 

The  gonococcus  of  N  e  i  s  s  e  r  may  diffuse  itself  and  give  rise  to  inflam- 
matory conditions  in  the  pleural  cavity,  as  well  as  in  other  serous  cavities 
(M  a  z  z  a).  It  is  probable  that  the  Bacterium  coli  commune,  the  migrating 
character  of  which  has  been  established  beyond  doubt  (W  y  s  s  ,  T  a  v  e  1),  is 
occasionally  the  infecting  agent. 

The  occurrence  of  a  perforating  gastric  ulcer  in  the  upper  and  posterior 
stomach  wall  may  give  rise  to  subphrenic  abscess,  the  pus  making  its  way 
along  the  muscular  planes  of  the  diaphragm,  finally  emptying  into  the  pleural 
cavity  and  there  exciting  a  septic  pleuritis. 

The  prognosis  in  simple  pleuritis  with  effusion  is  always  favorable. 
Aseptic  aspiration,  even  if  only  a  portion  of  the  fluid  is  removed,  is  always 
followed  by  recovery.  In  septic  pleuritis  recovery  usually  follows  appropriate 
surgical  treatment.  In  cases  in  which  the  effusion  is  of  tuberculous  or  can- 
cerous origin,  and  in  pyemic  gangrene  of  the  pleura,  the  prognosis  is  most 
grave. 

Delay  in  operative  interference  in  septic  and  suppurative  pleuritis  may  lead 
to  mpture  into  a  bronchus  and  evacuation  of  the  cavity  by  coughing.  Cure 
occasionally  takes  place  in  this  manner.  This  method  of  evacuation  is  fraught 
with  danger,  however,  since  the  discharge  may  be  so  profuse  as  literally  to 
drown  the  patient  in  his  own  pus. 

The  persistence  of  a  seropurulent  fluid  in  the  pleural  cavity  is  known  as 
chronic  empyema.  There  is  progressive  thickening  of  the  pleura  due  to  the 
deposition  of  successive  layers  of  fibrin,  compression  of  the  lung  until  the  latter 
occupies  but  an  extremely  small  portion  of  the  corresponding  half  of  the  thoracic 
cavity,  and  the  formation  of  dense  adhesions  which  imprison  the  lung  and 
prevent  its  expansion. 

The  Surgical  Treatment  of  Pleuritic  Effusions.  —  If,  after  a  reason- 
able trial  of  salines  and  hydragog  cathartics,  a  simple  serous  effusion  is  not 
removed,  operative  measures  must  be  resorted  to.  When  the  effusion  is  puru- 
lent from  the  commencement,  the  employment  of  such  measures  is  but  a  waste 
of  time;  the  longer  the  operative  interference  is  postponed,  the  greater  the 
difficulties  encountered,  owdng  to  the  thickening  of  the  pleura  and  the  forma- 
tion of  adhesions  in  securing  expansion  of  the  lung  after  evacuation  of  the 
fluid. 

Simple  Puncture  and  Aspiration. — This  is  indicated  as  follows:  (1)  In 
cases  of  rapid  accumulation  in  which  great  dyspnea  arises  from  compression  of 
the  lung,  before  compensatory  expansion  of  the  other  lung  can  take  place.  (2) 
In  cases  of  slow  accumulation  in  which  absorption  is  prevented  by  pressure, 
-two-thirds  or  more  of  the  corresponding  half  of  the  thoracic  cavity  being 
-occupied  by  the  fluid.  If  the  serous  effusion  is  due  to  the  presence  of  tubercu- 
lous disease,  the  improvement  will  be  only  temporary.  (4)  In  doubtful  cases 
ior  purposes  of  exploration. 

AVhen  the  effusion  is  large,  the  pleural  cavity  can  be  punctured  at  different 
places.  In  encysted  or  encapsulated  effusions,  the  fluid  developing  between 
different  layers  of  adhesions,  or  where  the  cavity  of  the  pleura  is  divided  into 
several  compartments  by  adhesions  between  the  interior  of  the  chest  wall  and 
the  pulmonary  pleura  at  different  points,  repeated  punctures  may  be  necessary 


THE    BONY   CHEST   WALLS  677 

before  locating  the  fluid.  The  latter  may  also  occupy  several  separate  spaces 
(multiple  encapsulation).  In  ordinary  cases  the  puncture  is  usually  made 
in  the  lateral  thoracic  region  on  the  axillary  line,  and  in  either  the  fifth,  the 
sixth,  or  the  seventh  intercostal  space.  A  puncture  on  a  line  with  the  angle  of 
the  scapula  is  safe  on  either  side. 

A  slight  incision  in  the  skin  may  be  made  if  the  operator  so  fancies.  If 
this  is  done,  cocain  anesthesia  should  be  employed.  Usually,  in  large  effusions, 
the  intercostal  spaces  are  prominent  and  the  puncture  is  easily  made.  The 
point  of  the  left  index-finger  is  pressed  firmly  in  the  intercostal  space  to  steady 
the  trocar  and  prevent  it  from  gliding  off  on  the  surface  of  the  rib  as  the  patient 
makes  a  quick  respiratory  movement  at  the  contact  of  the  instrument.  The 
latter  should  hug  the  upper  edge  of  a  rib  to  avoid  the  intercostal  artery.  When, 
from  any  reason,  it  becomes  necessary  to  puncture  in  the  lower  intercostal 
spaces,  the  point  of  the  trocar  must  be  directed  obliquely  upward  to  avoid  injury 
to  the  diaphragm,  and  to  the  liver  on  the  right  and  the  spleen  on  the  left  side. 

During  the  operation  of  tapping,  the  fluid  should  be  permitted  to  escape 
only  slowly,  in  order  to  avoid  circulatory  disturbances  in  the  heart  and  large 
vessels,  the  formation  of  coagula  on  the  walls  of  the  latter,  and  the  loosening 
and  subsequent  passage  of  these  into  the  pulmonary  arteries.  These  pre- 
cautions are  doubly  necessary  in  left-sided  effusions,  the  heart  being  displaced 
to  the  right  (dextrocardia).  Hence,  these  disturbances  are  more  likely  to 
occur  if  the  heart  is  suddenly  permitted  to  resume  its  normal  position.  The 
flow  should  be  interrupted  from  time  to  time  by  compressing  the  tube  or  by 
placing  the  finger  over  the  open  end  of  the  cannula. 

When  the  aspirating  trocar  is  used,  air  is  effectually  prevented  from  enter- 
ing and  the  flow  is  continuous,  the  lung  expanding  to  replace  the  evacuated 
fluid.  WTiether  the  tapping  is  performed  with  an  ordinary  trocar  or  with 
an  aspirating  apparatus  the  lumen  of  the  instrument  may  become  obstructed 
by  flbrinous  material  and  require  clearing  by  means  of  a  blunt  probe  or  a  wire. 

In  pleuritic  effusions  complicating  well-marked  tuberculous  disease  of  the 
lungs  aspiration  should  be  delayed  until  demanded  by  purulent  changes  in  the 
fluid,  as  shown  by  exploratory  puncture,  considerable  displacement  of  the 
heart,  and  marked  increase  in  the  ch^spnea. 

Incision  (Thoracotomy). —  This  is  indicated  (1)  in  cases  in  which  there  are 
constantly  recurring  effusions  that  are  nontuberculous  and  nonmalignant ;  (2) 
in  cases  of  primary  septic  or  suppurative  pleuritis  and  in  cases  of  septic  infection 
of  previously  existing  serous  effusion.  It  may  also  be  resorted  to  in  cases  in 
which  repeated  tapping  has  failed.  It  is  rarely  employed  at  the  present  day 
except  in  children.  The  operation  is  made  in  the  localities  indicated  for  tap- 
ping. The  skin  incision  is  made  over  an  interspace  and  the  muscular  tissues 
and  serous  membrane  divided  in  turn.  The  fluid  must  not  be  permitted  to  flow 
away  too  rapidly.  Where  the  effusion  is  large  and  recent,  it  is  better  to  remove 
a  portion  of  the  fluid  first  by  slow  tapping,  or  aspiration.  In  effusions  of  long 
standing,  as  well  as  in  "empyema  of  necessity,"  w^here  the  pus  from  a  pj'-othorax 
has  found  its  way  beneath  the  thoracic  muscles,  this  precaution  is  not  necessary. 

The  incision  is  made  about  three  inches  in  length  in  a  longitudinal  direction 
in  the  midaxillary  line  at  the  upper  border  of  the  sixth  or  seventh  rib.  Incision 
is  usually  supplemented  by  tube  drainage.  Irrigation  of  the  chest  cavity 
should  not  be  employed.     In  recent  cases  of  empyema  in  young  children  recov- 


678 


THE  SURGERY  OF  THE  THORAX 


ery  has  sometimes  been  quite  raj3id  under  this  treatment.  When  the  hmg  is 
collapsed  from  compression,  as  well  as  from  cicatricial  contraction,  the  cure  is 
tedious,  from  failure  of  obliteration  of  the  suppurating  cavity.  In  young 
subjects  the  obliteration  sometimes  takes  place  at  the  expense  of  the  chest  wall, 
the  latter  collapsing  from  above  downward,  and  lateral  curvature  of  the  spinal 
column  (scoliosis)  results.     As  a  further  effect  of  this  collapse  of  the  chest 


Fig.  394. — Position  for  Operations  ox  the  Chest  Walls  and  on  the  Pleura,  Lungs,  etc. 

wall  the  intercostal  spaces  are  narrowed  and  the  elastic  drainage  tube  is  com- 
pressed. Metal  tubes  are  unsatisfactory,  and  the  best  result  under  these 
circumstances  is  obtained  by  resection  of  a  portion  of  one  or  more  ribs. 

Resection  of  a  Portion  of  Rib. —  This  is  usually  the  procedure  of  choice  in 
adults  and  is  frequently  necessary  in  children.  Where  considerable  dyspnea  is 
present,  and  the  voluntary  muscles  of  respiration  are  brought  into  play  to  assist 
in  breathing,  a  general  anesthetic  should  be  avoided  and  the  operation  per- 


FlG.    39.5. COSTOTOME. 


formed  under  local  anesthesia  (cocain).  Some  surgeons  advise  that  aspiration 
be  employed  the  day  previous  to  the  operation,  to  permit  the  use  of  a  general 
anesthetic.  The  patient  should  be  placed  supine,  or  nearly  so,  in  order  to 
permit  free  expansion  of  the  sound  lung  (Fig.  394).  The  incision  should 
expose  the  sixth  rib  in  the  midaxillary  line  so  as  to  permit  the  removal  of  an  inch 
or  more  of  the  rib.     The  latter  is  divided  by  the  costotome  (Fig.  395)  in  two 


thp:  bony  chest  walls  679 

places  about  one  inch  apart,  and  the  intervening  piece  grasped  by  the  bone 
forceps  and  finally  freed  and  removed.  By  proceeding  in  this  manner  the 
investing  periosteum  is  removed  with  the  section  of  rib,  and  the  narrowing  of 
the  opening  by  the  rapid  formation  of  bone  prevented.  The  intercostal  artery 
will  require  ligation  at  each  side  of  the  incision. 

Thoracoplasty. — Plastic  operations  on  the  chest  wall  are  employed  as 
secondary  procedures  in  cases  of  empyema  in  which  the  collapsed  lung  is  pre- 
vented from  expanding  by  the  presence  of  dense  adhesions  and  thickened 
pleura;  and  in  cases  in  which  partial  expansion  takes  place,  the  rigid  chest  wall 
failing  to  collapse  sufficiently  to  effect  its  proper  approximation  to  the  lung.  It 
is  indicated  as  a  primary  operation  in  old  cases  of  empyema  in  which  the  above 
conditions  are  revealed  at  the  outset  by  the  resection  of  a  portion  of  rib. 

Estlander's  operation  consists  of  the  removal  of  portions  of  the  second, 
third,  fourth,  fifth,  sixth,  and  seventh  ribs.  These  may  be  reached  through 
three  transverse  incisions,  two  ribs  being  removed  through  each  incision.  Or, 
a  vertical  incision  or  a  U-shaped  flap  maj^  be  used.  In  order  to  prevent  repro- 
duction of  the  ribs,  which  would  defeat  the  object  of  the  operation,  namely,  the 
permanent  collapse  of  the  chest  wall,  the  periosteum  must  be  removed  with  the 
ribs.  Irrigation  of  the  cavity  is  usually  safe  in  cases  in  which  this  operation  is 
indicated.  The  incisions  are  closed  ^^■ith  silkworm-gut  and  cavities  are  drained 
by  a  large  tube.     Small  cavities  may  be  packed  with  antiseptic  gauze. 

Schede's  operation  is  designed  to  accomplish  the  same  object  as  E  s  t  - 
lander's,  but  in  a  more  radical  manner.  By  means  of  this  procedure,  not 
only  the  ribs  with  the  periosteum  are  removed,  but  the  thickened  parietal 
pleura  and  intercostal  muscles  as  well.  The  operation  is  to  be  reserved  for  that 
class  of  cases  in  which  the  pleura  is  greatly  thickened,  and  in  which  the  removal 
of  portions  of  the  ribs  alone  will  not  suffice  to  secure  collapse  of  the  chest  wall  to 
fill  the  space  formerly  occupied  by  the  fluid. 

The  operation  is  performed  as  follows:  The  bony  chest  wall  is  bared  by 
reflecting  a  modified  U-shaped  flap  in  an  upward  direction.  The  incision 
marking  out  this  flap  commences  in  front  at  the  outer  edge  of  the  pectoral 
muscle,  on  a  level  with  the  fourth  rib,  passes  downward  to  curv^e  at  the  level  of 
the  tenth  rib,  is  carried  thence  to  the  midaxillari'  line,  from  which  point  it  again 
curves  and  passes  to  the  posterior  scapular  line,  thence  continuing  upward  along 
a  line  midway  between  the  vertebral  border  of  the  scapula  and  the  spinous 
processes  to  the  level  of  the  second  rib  (Fig.  396).  The  arm  is  elevated  so  as  to 
reach  the  tubercles  of  the  upper  ribs  that  are  to  be  removed.  The  incision  is 
carried  down  to  the  ribs  throughout  its  entire  length,  the  soft  parts  turned 
upward,  the  scapula  displaced  and  the  ribs  successively  divided,  first  along  the 
costochondral  articulations  and  then  at  the  tubercles,  and  this  portion  of  the 
chest  wall  removed  in  one  mass,  including  the  pleura  and  intercostal  muscles. 
The  flap  is  then  replaced  with  its  raw  surface  resting  against  the  visceral  layer 
of  the  pleura  and  sutured  with  silkworm-gut.  Drainage  is  provided  for  by  one 
or  more  drainage-tubes. 

Pleurotomy  with  detachment  of  the  visceral  layer  of  the  diseased 
pleura  (pulmonary  decortication.  D  e  1  o  r  m  e  ,  1S94)  is  employed  for  the 
purpose  of  releasing  the  lung  from  its  environment  of  thickened  and 
adherent  pulmonary  pleura.  An  incision  is  made  through  the  visceral  pleura 
and  the  opening  thus  made  extended  by  merely  separating  the  investment 


680  THE  SURGERY  OF  THE  THORAX 

of  the  lung  or  by  both  separating  and  cutting  away  the  pleura.  Good  results 
have  been  obtained  by  this  procedure,  even  in  cases  in  -which  the  lung  failed  to 
expand  at  first. 


Fig.  396. — Lines  of  I^.cision'  fob  Schede's  Opeeation  of  Thoracoplasty. 


Fig.  397.     The  Author's  Lines  of  1s(  i<ios  fob  Resecting  the  Ribs  in  Pleurectomt. 

Total  pleurectomy  was   first   performed   on  October  27,  1893,  by  the 
author  in  a  case  of  chronic  empyema  of  two  years'  standing.*     A  portion  of  the 

*  "  Medical  Record,"  December  .30,  1893. 


Til  10    LUNGS  681 

bony  chest  wall  was  resected  and  the  entire  pleura  dissected  away  as  a  dense 
fibrous  cicatricial  mass.  The  patient,  a  rather  delicate  woman,  completely 
and  permanently  recovered. 

The  operation  is  indicated  when  the  lung  is  bound  down  with  dense  ad- 
hesions so  that  expansion  is  impossible,  and  where  Estlander  's  oj^eration 
has  failed.  It  may  even  replace  the  latter.  It  is  to  be  preferred  to  the  exten- 
sive resection  of  the  ribs  and  the  partial  pleurectomy  ofSchede's  operation. 
The  procedure  attacks  the  two  causes  of  failure  of  cure  of  empyema,  namely, 
inability  of  the  lung  to  expand,  and  the  presence  of  an  infected  mass  of  fibrous 
cicatricial  tissue  replacing  the  pleura.  It  should  not  be  employed  in  cases 
demonstrably  tuberculous  in  character. 

If  the  case  has  not  been  previously  operated  on,  an  opening  is  made  in  the 
sixth  intercostal  space  and  the  interior  of  the  chest  explored  with  the  finger. 
If  the  indications  for  total  pleurectomy  present  themselves,  the  incision  should 
be  extended  as  above  indicated. 

The  operation  is  performed  as  f ollow^s :  If  a  sinus  is  present  from  a  jDrevious 
operation  for  drainage,  this  is  lengthened  in  either  direction  along  the  cor- 
responding intercostal  space,  until  the  latter  is  opened  to  the  extent  of  from 
8  to  9  inches.  A  vertical  incision  is  made  from  the  posterior  termination  of  this 
incision  in  a  downward  direction,  and  another  from  its  anterior  extremity  in  an 
upward  direction  (Fig.  397).  The  two  triangular  shaped  flaps  thus  marked 
out  are  reflected,  the  first  downward  and  backward,  and  the  second  upward 
and  forward,  to  an  extent  sufficient  to  gain  access  to  four  ribs,  and  the  latter 
are  resected  for  about  eight  inches.  The  removal  of  the  pleura  is  effected  by 
blunt  dissection,  the  "peeling"  process  proceeding  so  as  to  remove  the  visceral 
layer  last.  An  incision  across  the  latter  will  permit  removal  of  the  pleural 
membrane  at  this  point  without  injury  to  the  lung.  The  latter  expands  some- 
what as  it  is  released,  in  spite  of  the  large  opening  in  the  chest  wall,  and  usually 
fills  a  considerable  portion  of  the  chest  cavity  at  the  comj^letion  of  the  operation. 
The  flaps  are  replaced  and  sutured,  provision  being  made  for  drainage.  If  the 
cavity  is  thoroughly  cleansed  before  the  operation,  irrigation  is  omitted. 

Separation  of  the  Ribs  from  the  Sternum.— This  has  been  suggested 
( J  a  b  o  u  1  a  y)  as  a  substitute  for  Estlander's  procedure,  or  as  sup- 
plementary to  it,  where  the  greatest  diameter  of  the  suppurating  cavity  is 
vertically  placed.  The  first  seven  ribs  are  separated.  In  some  cases  it  may 
be  necessary  to  resect  portions  of  rib  as  well.     , 

THE  LUNGS 

Abscess  of  the  Lung. — ^This  may  follow  ordinary  pneumonia,  when  it  is 
usually  single;  it  is  more  likely,  however,  to  follow  aspiration  pneumonia,  in 
which  case  there  are  usually  multiple  abscesses.  It  may  result  from  a  sub- 
diaphragmatic abscess  following  appendicitis,  the  infection  propagating  along 
the  lymph-channels  of  the  diaphragm.  It  may  occur  in  the  course  of  cancer  of 
the  esophagus  or  foUow  a  wound  of  the  lung,  with  or  without  lodgment  of  a 
foreign  body.  Infectious  emboli  may  lodge  in  the  vessels  of  the  lung  tissue, 
causing  multiple  abscesses  (metastatic  abscess).  Pneumococci,  streptococci, 
staphylococci,  or  colon  bacilli  may  be  present. 

The  expectoration  is  very  offensive,  and  in  it  fragments  of  lung  tissue  may 


682  THE  SURGERY  OF  THE  THORAX 

be  detected  by  microscopic  examination.  It  is  coughed  up  in  mouthfuls  during 
paroxysms  of  coughing  occurring  several  hours  apart.  There  is  dullness  on 
percussion  if  the  abscess  cavity  is  large  and  full  of  pus.  The  physical  signs  of 
a  cavity  are  present  as  the  abscess  is  emptied  of  pus  and  air  enters.  Small 
pyemic  or  metastatic  cavities  may  be  overlooked. 

The  treatment  consists  in  resection  of  a  portion  of  rib,  the  cavity  being 
located  with  the  aspirating  needle,  and  the  needle,  which  is  left  in  for  the  pur- 
pose, followed  as  a  guide,  the  lung  over  the  cavity  incised  with  the  thermo- 
cautery, and  a  rubber  drainage-tube  introduced.  If  the  two  layers  of  pleura 
are  not  adherent  over  the  abscess  cavity,  and  the  latter  can  be  temporarily 
emptied  by  aspiration,  the  opening  in  the  chest  wall  may  be  tamponed  for  two 
or  three  days  until  adhesions  have  formed.  If  the  pus  cannot  be  aspirated  and 
the  symptoms  are  urgent,  the  place  where  the  opening  is  to  be  made  may  be 
walled  off  by  iodoform  gauze  and  the  operation  proceeded  with.  The  opera- 
tion should  he  performed  under  chloroform  or  local  anesthesia.  If  the  former 
is  employed,  its  administration  may  be  suspended  as  soon  as  the  lung  tissue 
is  reached,  as  the  latter  is  quite  insensitive. 

Gangrene  of  the  Lung. — The  invasion  of  the  lung  tissue  by  pyogenic 
microorganisms  is  sometimes  followed  by  complete  devitalization  of  the  former 
and  consequent  gangrene.  The  invasion  may  result  from  injuries  or  operations 
about  the  mouth  (cancer  of  the  tongue,  etc.);  from  wounds  of  the  lung  or  the 
lodgment  of  foreign  bodies  in  the  lung,  embolism  of  the  pulmonary  artery, 
pneumonia  or  bronchitis,  and  tuberculous  or  malignant  disease  of  the  lung. 
The  gangrene  may  be  diffused  or  circumscribed  and  may  occur  in  single  or 
multiple  areas.  The  lung  tissue  putrefies,  softens,  and  is  coughed  up,  a 
gangrenous  cavity  remaining. 

Symptoms. — Expectoration  is  infrequent  and  sometimes  absent;  the 
expectorated  matter  is  usually  large  in  quantity  and  horribly  offensive. 
The  odor  of  the  breath  is  repulsively  foul.  The  patient  hes  on  the  diseased 
side.  The  physical  signs  may  be  either  those  of  consolidation  or  those 
of  a  cavity.  Pulmonary  hemorrhage  may  occur.  .  Spontaneous  cure  may, 
though  rarely,  take  place,  the  cavity  becoming  surrounded  by  adhesions  and 
obliterated  by  granulations.  Death  may  occur  in  a  few  days,  or  the  patient 
may  live  for  several  weeks  and  finally  succumb  from  exhaustion. 

Treatment. — An  attempt  to  reach  the  gangrenous  area  and  effect  drainage 
should  be  made,  as  in  pulmonary  abscess.  In  order  to  prevent  pneumothorax 
the  operation  may  be  performed  in  two  stages,  as  in  abscess  of  the  lung. 

Operations  on  Cavities  in  the  Lung. — ^The  first  recorded  attempt 
to  reach  a  cavity  in  the  lung  was  made  in  1664  (Willis).  Several  attempts 
were  made  by  B  a  r  r  y  (1726).  The  first  to  emjDloy  antiseptic  applications  was 
Hosier  (1873).  E  .  Bull  collected  the  statistics  of  26  cases  of  operations 
on  the  lung.  Of  these  cases,  4  were  cured,  15  were  improved,  and  in  7  the  pro- 
cedure was  followed  by  no  improvement  whatever.  In  addition  to  these, 
Ijauenstein  operated  successfully  for  bronchiectasis.  Pyemic  abscess  of 
the  lung  has  also  been  cured  by  operation. 

The  indications  for  pneumotomy,  therefore,  may  be  said  to  be  bronchiec- 
tasic  cavities,  abscesses  of  the  lung  near  the  surface,  pyemic  infarcts,  foreign 
bodies,  echinococcus  cysts  near  the  surface,  and  single  tuberculous  cavities  with 
slight  outlying  infection  in  cases  in  which  the  disease  is  only  slowly  progressive. 


THE    LUNGS  683 

The  operation  is  generally  useless  in  tuberculous  cavities,  on  account  of  the  wide 
infection  of  the  pulmonary  tissues.  Before  the  operation  can  be  proceeded 
with,  it  must  be  determined,  if  possible,  that  adhesions  exist  between  the  seat 
of  the  lesion  and  the  chest  wall.     In  old  abscesses  these  are  usually  present. 

Where  adhesions  cannot  be  demonstrated  beforehand,  the  introduction  of 
an  exploring  needle,  after  incising  to  the  pleura  in  an  intercostal  space,  may  give 
the  necessary  information  if  note  is  taken  of  the  depth  to  which  the  needle 
passes  before  the  appearance  of  pus  in  the  exhausted  barrel  of  the  syringe; 
further,  if  it  is  demonstrated  that  the  needle  remains  stationarv^  during  the 
respiratory  movements,  it  may  be  taken  for  granted  that  the  instrument  has 
passed  through  a  solid  adhesion.  If  no  adhesions  are  present,  it  is  better  to 
postpone  the  operation,  except  where  urgent  symptoms  are  present,  else  pneu- 
mothorax may  foUow  the  operation.  After  the  exploratory^  puncture,  resection 
of  a  rib  is  performed  and  the  abscess  or  other  cavity  finally  reached  by  means  of 
the  thermocautery  (see  Fig.  96). 

Pneumectomy,  or  resection  of  the  diseased  area,  has  been  successfully  per- 
formed (T  u  f  f  i  e  r),  but  has  not  met  with  general  acceptance. 

Injection  of  nitrogen  into  the  pleural  sac  for  the  purpose  of  occluding 
the  lymph-channels,  preventing  hemorrhage,  and  effecting  compression  of  the 
lung  and  the  development  of  fibrous  tissue  in  order  to  favor  healing  of  the 
cavity,  has  been  empWed  (J  .  B  .  Murphy).  Every  three  or  four  weeks 
120  c.c.  of  nitrogen  gas  are  injected. 

Resection  of  an  adjacent  portion  of  lung  was  performed  by  K  r  o  n  1  e  i  n 
while  operating  for  sarcoma  of  the  ribs.  Experiments  on  the  lower  animals  for 
resection  of  lung  substance  were  carried  out  successfully  by  S  c  h  m  i  d  and 
others. 

Tumors  within  the  Thoracic  Cavity.  —  Primary  Sarcoma  of  the 
Lung. — This  occurs  as  a  large  tumor,  extending  at  first  within  the  thoracic 
cavity  and  then  forcing  its  way  between  the  ri])s,  and  finally  crowding  the  latter 
outward.  The  soft  parts  of  the  chest  finally  become  involved.  These  growths 
are  likely  to  be  mistaken  for  chrondromas,  and  vice  versa. 

Echinococcus  of  the  Lung. — Tliis  ma}^  occup}^  a  central  position  in  the 
lung  or  attack  the  periphery  and  extend  to  the  pleural  cavity.  It  may  also  exist 
as  an  extension  from  the  pleura  or  from  the  liver,  reaching  the  lung  b}'  successive 
involvement  of  the  diaphragm  and  pleura.  When  occurring  primarily  in  the 
central  portion  of  the  lung,  the  first  evidence  of  its  presence  is  the  appearance 
of  the  characteristic  cysts  in  the  sputum.  When  the  periphery'  is  attacked,  and 
encapsulated  pleuritis  is  supposed  to  exist,  the  diagnosis  is  made  only  when 
exploratory  puncture  is  performed.  The  treatment  is  limited  to  inhalations  of 
antiseptic  vapors  (turpentih  in  hot  water)  to  prevent  septic  complications. 

Intrathoracic  Aneurism. — This  usualh^  commences'  as  a  cylindric  en- 
largement of  the  arterial  tube,  aftei'\\'ard  developing  into  the  sacculated  variety. 
The  intercostal  spaces  are  at  first  widened  by  the  powerful  impulse  of  the  tumor; 
destruction  of  the  bony  chest  wall  follows,  and  finally  a  pulsating  tumor  makes 
its  appearance.  In  case  the  arch  of  the  aorta  is  involved  the  swelling  is  below 
the  left  clavicle,  and  in  the  neighborhood  of  the  first,  second,  and  third  ribs. 
In  aneurism  of  the  innominate  artery  the  tumor  presents  in  the  middle  line  and 
to  the  right  (Fig.  398).  The  destruction  of  the  bony  structure  is  accom- 
panied by  constant  gnawing  pains.     Life  is  threatened  by  the  nipture  of  the 


684 


THE  SURGERY  OF  THE  THORAX 


aneurismal  sac.  As  a  palliative  measure  it  is  recommended  to  place  narrow 
strips  of  gauze  over  the  tumor,  and  apply  contractile  collodion  over  these. 
(See  Operations  for  the  Cure  of  Aneurism.) 

Hernia  of  the  Lung. — This  occurs  at  the  upper  opening  of  the  thoracic 
cavity,  the  lung  being  forced  into  the  supraclavicular  fossa  by  deep  expiration, 
where  its  presence  can  be  demonstrated  by  percussion.  It  has  also  been  observed 
projecting  in  the  upper  intercostal  spaces  and  in  front,  as  a  result  of  congenital 
absence  of  the  costal  cartilages.  A  traumatic  form  has  been  described  following 
extensive  destruction  of  the  chest  wall,  the  resulting  cicatrix  yielding  under 


Fig.  .398. ^Aneurism  of  the  Inxomixate  Artery   (Dr.  T.  R.  M.\xfield's  Case). 

intrathoracic  pressure.  The  diagnosis  is  made  by  the  movements  of  the  tumor 
during  the  respiratory  acts  and  by  auscultation  and  percussion.  The  treat- 
ment is  only  palliative,  consisting  of  the  apphcation  of  properly  regulated 
pressure. 


THE  HEART  AND  PERICARDIUM 

Wounds  of  the  Heart  and  Pericardium. — These  generally  prove  immedi- 
ately fatal.  In  exceptional  cases  life  has  been  prolonged  for  a  short  time,  and 
in  rare  instances  recovery  has  taken  place.  Of  the  latter,  72  cases  are 
recorded,  in  which  the  diagnosis  was  subsequent^  confirmed  by  autopsy.  In 
12  cases  of  foreign  bodies  in  the  heart  in  which  recovery  occurred,  after  varying 
periods  of  time  autopsy  revealed  needles  in  6  cases,  bullets  in  5,  and  a  thorn 
in  one  case  (H  u  e  t  e  r).  Syncope  usually  occurs,  and  this  has  a  beneficial 
effect,  inasmuch  as  it  favors  thrombosis  and  arrest  of  hemorrhage.  Oblique 
punctured  wounds  of  the  ventricles  are  less  rapidly  fatal  than  wounds  of  the 


THE    HEART   AND    PERICARDIUM  685 

auricles.  The  comparatively  thin  muscular  walls  of  the  latter  do  not  favor 
closure  of  the  opening. 

Treatment. — Heretofore  this  has  been  limited  to  closure  of  the  external 
wound.  In  view  of  the  fact  that  death  usually  takes  place  from  inhil^ition  of 
the  heart's  action  dvie  to  overfilling  of  the  pericardium  with  effused  blood,  the 
attempt  may  be  made  to  reach  the  cavity  of  the  latter,  either  through  the  wound 
or  by  resection  of  one  or  more  ribs  (pericardiotomy)  and  to  relieve  the  pressure 
(E.  Roser).  Search  for  foreign  bodies  and  removal  of  them,  arrest  of  hem- 
orrhage and  suture  of  the  wound  in  the  ventricle  will  naturally  follow.  Vene- 
section has  been  proposed  (S  t  r  o  m  e  y  e  r),  and  was  successfully  carried  out 
by  Rose  in  a  case  in  which  extreme  cyanosis  and  marked  increase  in  the  area 
of  heart  dullness  were  present  after  a  stab  wound  of  the  heart. 

Dropsy  of  the  Pericardium.— This  occurs  as  a  result  of  serous  peri- 
carditis and  may  demand  surgical  interference  to  ward  off  impending  death 
from  paralysis  of  the  heart.  Puncture  and  aspiration  (paracentesis  of  the 
pericardium,  B  .  F  .  W  e  s  t  b  r  o  o  k)  are  not  difficult  of  performance.  The 
area  of  dullness  and  the  bulging  intercostal  spaces  form  a  ready  guide  for  the 
introduction  of  the  trocar  or  needle.  The  heart  is  usually  crowded  well  back 
and  out  of  the  way  of  injury.  The  upper  edge  of  the  sixth  costal  cartilage  near 
the  left  lateral  edge  of  the  sternum  is  the  most  favorable  place  for  the  puncture. 
The  operation  is  practically  without  danger  if  aseptic  precautions  are  observed 
and  entrance  of  air  avoided. 

Pyopericardium. —  This  results  from  suppurative  pericarditis.  Pericar- 
diotomy, followed  by  drainage,  is  indicated.  The  incision  is  made  near  the 
left  edge  of  the  sternum,  between  the  fourth  and  the  fifth  costal  cartilage. 
Pneumopyopericardium  constitutes  an  urgent  indication  for  the  prompt 
performance  of  incision  and  antiseptic  treatment.  The  condition  is  recognized 
by  a  tympanitic  percussion  note,  and  succussion  sounds  occurring  synchron- 
ously with  the  heart's  action.  It  may  result  from  the,  development  of  gases 
from  putrefaction  in  suppurative  pericarditis,  from  the  breaking  down  of  pul- 
monary tissue  in  communication  with  the  pericardium,  from  extension  from 
the  pleural  cavity,  from  communication  with  a  bronchus,  or  from  simultaneous 
gunshot  wounds  of  the  lung  and  pericardium. 


INDEX  OF  NAMES 


Abbe,  541,  542,  622,  623,  638 

Adams,   122,  362,  363,  460,  529 

Alexander,  472,  637,  640 

Allen,  107 

Allen  (Harrison),  496 

Allis,  292 

Althann,  439 

Ammentorp,   212 

Annandale,  577 

Antvllus,  345 

Arnold,  20,  21,  51,  53 

Arnold  (J.),  4,  5,  206 

Aronsohn,  41 

Asch,  496 

Ascherson,  640 

Ashhurst,  635 


Babes,  205 

Baccelli    190 

Ballance,  85,  90,  91,  340,  341,  380,  626 

Banks,  635 

Bardeleben,  61,  621,  629 

Bardenheuer,   134 

Barnes,  497 

Barry,  682 

Bartley,  290 

Barton,  405,  406,  407,  521.  522 

Baumgarten,  33,  205,  206,  209 

Beckniann,  265,  266 

Beclard,  45 

Becquerel,  45 

Beely,  493 

Behring,  190 

Bellocq,  497,  498 

Bence,  260,  261 

Benda,  205 

Bengue,  302 

Bennett,  544 

Bergmann,  44,  55,  59,  183,  439,  450,  472 

Bernard,  437,  439 

Bernhardt,  465 

Bernstein,  288 

Bert,  301 

Bier,  208,  209,  388,  393 

Billroth,  16,  82,  113,  188,  213,  375,  553,  569, 

608,  609,  617,  622,  624,  625,  656,  657,  658, 

662, 673 
Bincks,  262 
Birch-Hirschfeld,  184 
Bird  (Golding),  488,  489 
Birkett,  229 
Bischer,  611 
Blandin,  489,  490 
Blasius,  625,  645 


Bochdalek,  592 

Boeckmann,  45,  54 

Boerhave,  618 

Bole,  52 

Bollinger,  209 

Bolton,  21,  27,  28 

Bond,  551 

Bosworth,  500,  502,  572,  576,  599 

Bouchard,  265 

Bowlby,   115,   118 

Brasdor,  344,  346,  632,  636 

Bratz,  55 

Braun,  541,  588,  640 

Brieger,   188 

Briggs,   107,  635 

Bristow,  28,  31 

Broca,  469,  635 

Brophy,  559,  563,  564 

Brown-Sequard,  41 

Brunner,  55 

Bruns,  63,  157,  169,  318,  355,482,  483,  503, 

504,  507,  508, 509, 632 
Bruns  (L.),  468 

Bruns  (P.),  91,  179,  209,  354,  610,  629 
Bryant,  91 

Bryant  (Joseph  D.)  378 
Buck  (Gurdon),  134,  403 
Bull,  682 

Burdon-Sanderson,  16 
Burow,  61,  329 
Burrell,  647,  648 
Busch,  511 
Butlin,  551 
Byrne,  81 


Cabot,  248 

Caghill,  613 

Cagniard-Latour,  14 

Garden.  379 

Carnochan,  349,  477 

Caspary,  204 

Charcot,   145,   152,  154,  616 

Chassaignac,  626,  627,  640 

Chauveau,   16 

Cheatham,  306 

Cheever,  569 

Cheyne,  440,  470 

Cheyne  (Watson),  16,  32,  48,  189 

Chiene,  467 

Christmas,  32 

Cline,  529 

Clover,  293,  294,  302,  304 

Coates,  608 


687 


688 


INDEX    OF   NAMES 


Cohen,  601,  609 

Cohnhcim,  6,  7,  103,  104,  590,  617 

Coler,  169 

Colev,  179,  226,  632,  649 

Colics,  204 

Collin.  314,  320,  597,  598 

Cooper,  ()57 

Coote  (Holmes),  649 

Cornil,   119 

Corning,  305,  306 

Corradi,  34S 

Councilman,  32 

Crile,  283,  304,  305,  339,  345,  347,  352,  534, 

554 
Cripps  (Harrison),  635 
Crol't,  625 

Cruveilhier,   130,  492 
Cryer,  52S 
dishing,  626 
Czerny,  612,  624 


Da  Costa,  248 

Dagion,  451 

Dana,  638 

Daniels,  302,  304 

Dare    249 

Dawbarn,  349,  381,  512,  513,  550,  551 

Deguise,  5SS 

Delafield,  247 

Delatour,  58 

Delbet,  451 

Delepine,  91 

Delorme,  679 

Dent,  91 

Devaine,  183 

Dieffenbach,  328,  329,  360,  434,  494,  501 

Dieulafov,  320,  568 

Dobell,  503 

Dollinger,  549 

Dowd,  53,  54 

Doyen,  314,  316 

Dumarquav,  349 

Dunham,  23,  24,  247,  600 

Dupuytren,  130 

Duquesnel,  572 

Durante,   112,  209 

Duret,  438 

Dusch,  14,  15 


Edmunds,  85,  90,  91,  340,  341,  380 

Eiselberg,  213,  501 

Elliot,  385 

Elzholz,  250,  251 

Eppinger,  95 

Erb,  115 

Erlenma3^er,  262 

Esbach,  261,  262 

Esmarch,  116,  295,  337,  338,  339,  369,  380, 

393,531,629,661,670 
Estlander,  364,  432,  482,  483,  679,  681 
Eulenburg,  41 
Everson,  625 
Ewald,  274 


Fehling,  262 

Fell,  300 

Fergusson,  373,  491,  537,  539 

Finch,  501 

Finney,  328 

Finsen,  209 

Fischer  (G.),  629,  630,  632,  650 

Fischer  (H.),  438,  661,  670 

Fish,  172 

Fitch,  319,  320 

Fleischl,  249 

Flemming,  206 

Flothmann,  473 

Fluhrer,  313,  315,  448,  451 

Ford,  323,  325 

Foster  (Michael),  91 

Fowler,  63,  114,  301 

Fowler  (R.  S.),  226 

French,  499, 534,  568,  574,  578,  600,  622 

Frerich,  600 

Fricke,  495 

Friederich,  210 

Friedlander,  80 

Fiirb ringer,  52 


Galen,  4,  7 

Gait,  313,  314,  447 

Gardner,  651 

Gamier,  201 

Gaspard,  44 

Gibson,  406,  407 

Gigh,  312,  361,  362,  363,  446,  447,  535,  543 

Gilles,  651 

Girdner,  385,  448,  452 

Gleiss,  355 

Gluck,   116,  355 

Gottstein,  503,  575 

Graefe,  386,  619,  620 

Gram,  25,  26,  28,  29,  210 

Grange,  611 

Greenfield,  612 

Grubler,  247 

Gull,  616 

Gurlt,  434,  641,  671 

Gussenbauer,  216,  494,  577,  607,  609,  610 


Habert,  169 

Hagedorn,  63,  321,  322 

Hahn,  609,  610 

Haines,  262 

Hajek,  517 

Ha'lban,   184 

Halsted,  304,  305,  321,  341,  662,  666,  668 

Hardaway,  68 

Harrison,   144 

Hartley,  541,  542 

Harz,  209,  210 

Hayem,   117 

Hebra,  474 

Heidenhain,  45,  46,  265,  659 

Helferich,  511,  548 

Helmholtz,  45 

Henle,  60,  628 

Hennequin,  366 

Henning,  302 


INDEX    OF   NAMES 


689 


Hensinger,  639 

Heusser,  213 

Hewett(Prescott),  438,  440 

Hewitt,  294,  298 

HUdebrand,  205 

Hilton,  642 

Hirsehberg,  3S6 

HodenpvU  o4,  211 

Hodgkiii,  113,  114,  259 

HolYa,  651 

Holt,  216 

Horslev,  450,  472 

Hueter.  11,  15,42,60,84,90,  127,  142,153, 
155,  178, 179, ISO, 184,  186,  349,  354,  385, 
449,  543.  545.  558.  629,  630,  644,  674,  684 

Hunter,  4,  96.  346 

Hutchinson,  204 


Israel.  511 


Jaeoulay.  681 

Jacobson,  572 

Jacobson,  635,  636 

Janicke,   179 

Jansen,  518 

Jarvis,  504,  505,  575 

Javarro,  56 

Jenner,  251 

Jessett,  549 

Jones,  216,  260,  261 

Jonnescu,  472,  640 

Joseph,   194 

Jung,  245,  246 

Junker,  304,  305,  551,  552,  564 

Jurasz,  343 


Kapesser.  208 

Kappeler,  303 

Kaufmann,  587 

Keen,  121,  226,  318,  441,  443,  447,  449,  551, 

651 
Kellv,  51 
Keves,  201,202 
Kikuzi,  169 
Killian,  516,  518 
Kingslev,  560 
Kitasatb,  29,  44,  188,  190 
Klebs,  15,  16,  29,  183,  187,  205.  476,  492,  566 
Knapp,  521 
Koch,  13,  16,  20,  22,  30,  47,  59,  80,  184,  188, 

205 
Koch  (W.),  636 
Kocher,  56,   139,   142,  341,  439,  460,  472, 

518,  554,  577,  589,   611,   612,  613,  614, 

615,  616,  651 
Konig,   139.  205,  438,  477,  510,  511,  512, 

513, 619,  671,  675 
Korner,  45,  46 
Kramer,  450 
Kraske,  179 
Krause,  205.  541 
Kredel,  154 

Kronlein.  456,  463,  683 
Kruse,  205 


Kuhnt,  517 
Kiimmell,  265 
Kiister,  67,  475 
Kuttncr,  590 


Laborde,  300 

Laennec,  208 

LaGarde,   173,  383 

Lamoureux,  201 

Landerer.  55,  82,   142 

Langenbeck,  330,  349,  473,  483,  486,  487, 

488,  507,  553,  561,  588 
Langlois,  296 
Lannelongue,  81,  112 
Latour,  14 

Lauenstein.   179,  643,  682 
Laval,  176 
Lavoisier,  43 
LawTence,  577 
Lebert,  217 
Lee,  635 
LeFort,  635 
Leisrink,  63 
Lemaire,   14 
Leroy,  386 
Letievant,  354 
Levaditi,  205,  210 
Lexer,  512 
Ley  den,  42,  43 
Lichtwitz,  517 
Liebermeister.  41.  42,  43 
Lister,  14,  15,32,  59.  61.  62 
Liston,  314,  317,  364,  534 
Livingstone,  353 
Lizar,  539 

Loffler,  25,  29,  30,  32,  476,  566 
Longmore,   166,   171,   174 
Loos,  480 

Lossen.   130.  497.  541,  583 
Liicke,  139.  179.  540,  541.  544,  .590,  611,  613 
Lud^-ig,  45,  588,  589,  628,  630 
Luer,  364,  447 
Lugol,  252,  473 
Lustgarten,  29 
Luton,  613 
Lvittich,  95 


Macewen,  56,  317,  349,  363.  364,  445,  457 

Mackenzie.  622,  623 

Mackow,  96 

Madelung,  630 

Magendie.  44 

Magitot,  532 

Maisonneuve,  181,  622,  637 

Makins,  653 

Malgaigne,  486,  487,  488,  490 

:\Iandl."  612 

Manteuffel,  94 

Marchand,  5,  209 

Marshall,  237 

Martin,  101,  147 

Mason,  496 

Matas,  300,  305,  346,  347,  348,  523,  524,  525 

Mathieu,  649 

Maurange,  296 


690 


INDEX    OF   NAMES 


Maxfield,  6S4 

Mazza,  676 

McHurney,  332,  333 

McChesnev,  331 

McCoy,  529 

McGraw,  315 

Meckel,  540 

Metchnikoff,  205 

Meyer,  662,  663 

Middeldorpf,  505 

Mikulicz,  82,  352,   615,   617,   622,   624 

Mills,  241 

Mirault,  4.S6,  4S7,  48S 

Mitchell  (Weir),  115,  118 

Mohrenheim,  661,  664,  665 

Moiterseur,  24 

Moore,  348 

Morestin,  593 

Morgan  (de),  Campbell,  60,  483 

Morris,  141 

Morton,  307 

Mosengeil,  63 

Mosler;  682 

Mott,  632,  635 

Muller,  285 

Miiller  (E.),  212 

MiiUer  (P.),  285 

Muller  (W.),  212,  612 

Murphy,  341,  342,  544,  683 

Nasse,  205 

Naumver,  41 

Xauwerk,  209 

Xebinger,  518 

Neelsen,  25 

Neisser,  28,  154,  179,  676 

Nelaton,  385.  486,  487,  577 

Neuber,  56,  63 

Neumann,  612 

Ne^\i:on,  250 

Xicoladoni,  588 

Nicolaier,  29,  44,  188 

Nimier,  176 

Nocard,  205 

Nussbaum,  73,  296,  368,  534,  673 

Oberst,  305 

0'Hv.■^■eT.  300,  598.  604,  605 

Oilier,"  130,  138,  332,  445,  507 

Oppenheim,  466 

Ord,  616 

Orm.sbv,  294 

Orth,  205,  206 

Otis,  171 

Ottolengui,  523 

Paget,  658 

Paquelin,  79,  142,  316,  335 

Parham,  484 

Park,  343,  609 

Park  (Roswell),  31 

Parker,  596 

Parrish,  359 

Pa.steur,  14,  15,  16,  32,  192,  19 

Patlauf,  501 


Pat  ton,  306 
Pawlow,  589 
Pean,  340 
Perrier,  81 
Peterson,  179 
Petit,  336,  380,  549 
Petri,  22,  247 
Petrour,  32 
Phelps,  162 
Philipaux,  355 
Pick,  244.  245 
Pilcher,  63.  600 
Piorkowski,  194 
Pirogoff,  181 
Poirier,  655 
PoUtzer,  572 
Ponfick,  210 
Porta,  615 
Post,  637 
Potain,  320 
Pott.  149,  646,  647 
Poulet,  570,  572 
Praun,  518 
Prucz,  213 

QuERVAix  (de),  651 
Quincke,  41 


PiAXVIER,  119 

Reboul,  212 

ReckUnghausen,  6,  7,  95,  106,  139,  178 

Reger,  137,  166 

Rehn,  629 

Renault,  191 

Reverdin,  54,  68,  72,  331,  476,  495 

RejTiaud,  382 

Richardson,  474,  651 

Richet,  142,  607 

Richter,  322,  323 

Ricord,  196,  197,  204 

Riedel.  79,  91.  130,  179 

Riedinger,  501 

Riga,  557 

Riva-Rocci,  2.59 

Rizzoli;  362,  531 

Robert,  657 

Roberts,  314,  447,  523 

Roe,  623 

Rokitanskv,  208.  216 

Rontgen,  il4.   128.  174,  241,  451,  518,  619 

Rose,    188,   490,   492,    508,  534,   551,   560, 

564,   568,  624.  647 
Rosenbach,  108,  179,  186,  188 
Roser  (E.),  685 
Roth,  629.  632 
Rotter.  154,  514 
Roux,  205 
Rudaux,  529      - 
Rudtorffer,  494 
Rust,  649 
Ruth,  451 
Ruysch,  492 

Sachs,  41 
Salmon,  184 


INDEX    OF    NAMES 


691 


Salzer,  543 

Sandelin,  483,  484 

Sands ,  622,  G35 

Sayre,  70,  386,  620,  642 

Sciuipps,  55 

Schede,   59,   73,   344,    609,   610,    673,   679, 

680,  681 
Schellmann,  441 
Schimmelbusch,  50,  52,  53,  295,  512,  513, 

514 
Sclijernina;,  169 
Schleich,  304,  357 
Schmid,  683 
Schmidt,  47,  90 
Schroder,  14,  15 
Schulten,  483 
Schultze  (Franz),  14 
Schultze  (.^lax),  74 
Schutz,  32 
Schwalbe,  613 
Schwann,  14,  15 
Schwartz,  359 
Schwartze,  462 
Scriba,  359 
Sedillot,  44,  549 
Seguin,  465 
Senator,  42 
Sanger,  81,  476 
Senn,  142,  151,  344 
Serres,  629 
Shaw,  642 
Sick,  212,  213 
Sigg,  205 
Simmons,  105 

Simon,  261,  486,  488,  489,  652 
Smith,  184 
Smith,  635,  637 
Smith  (J.),  217 
Smith  (Stephen),  645 
Socin,  446,  615 
Sonnenburg,  60,  74,  543 
Speiss,  45 
Spicer,  574 
Spix,  543,  544 
Squire,  385 
Stacke,  462,  586 
Starke,  368 
Steinhaus,  33 
Stenson,  587 
Stepanow,  501 
Sternberg,  188 
Stevenson,  334 
Stewart,  626 
Stokes,  440,  470 
Strauss,  275,  276 
■  Strobe,  205 
Stromeyer,  360,  434,  438,  527,   685 
Suersen,  560 

Sutton,  214,  215,  221,  227,  236,  237,  478 
Sylvester,  296,  298,  299,  300 
Symes,  379 
Szumann,  351 


Tallqvist,  249 
Tavel,  53,  55.  56,  676 
Tavlor,  646,  647 


Teale,  202,  379 

Teevan,  451 

Tellender,  219 

Tliane,  467 

Thatcher,  252,  253,  266,  267 

Thiersch,  5,  49,  61,  62,  68,  72,  77,  81,  88, 
331,  332,  355,  431,  433,  447,  476.  495, 
500,  501,  513,  514,  539,  541,  615,  653,  666 

Thoma,  6 

Thoma,  249,  250 

Thomas,  367,  647 

Thorburn,  644 

Tiemann,  309,  387 

Tillaux,  115 

TiUmanns,  141,  354,  451,  505 

Toisson,  250 

Topfer,  275 

Traube,  42 

Trendelenburg,  56,  101.  209,  351,  508,  534, 
535,  551,  552,  554.  596,  603 

Treves,  631 

Trnka,  358 

Trombetta,  357 

Ti'ousseau,  622 

Tschisto-ontsch,  456 

Tuffier,  683 

Tuttle,  301 

TjTidall,  17 


Ullmann,  544 


Valentine,  357 

Valsalva,  98,  572,  594 

Vater,  239 

Velpeau,  415,  416,  539 

A'erneuil,  68,  504 

Virchow,  102,  186,  206,  214,  217,  611,  629, 

639 
Vogt,  101.  357,602 
Voit,  47 
Volkmann,  47.  53,  61,  80, 130,  136,  144,  151, 

154,   157.  318,  372,  424,  477,   548,   629, 

647,  648.  649 
Voltolini,  505 
Vulpian,  355 


Wagxer,  448,  629 

Wahl,  42 

Waller,  117 

Walton,  651 

Ward,  504 

Wardrop,  76 

AVare,  301.  303 

AA'arner.  291 

AVarren.  91,  181,  611,  662,  663,  666,  667 

AA'eber,  354,  537,  539 

AA^igert.  24,  25,  205,  210 

AA'eir.  465 

AA'eiss.  188,  617,  620 

AA^elch.  17,  26,  27,  49,  57,  322 

AA^ernber,  529 

AA^stbrook.  187,  685 

Westphal,  266 

AVliarton,  588,  590.  592 


692 

White,  465,  642 

Whitehead,  551,552,  559 

Wilde,  5S2 

Wille,  366,  367 

Williams,  234 

Willis,  682 

Wilms,  531 

Winiwarter,  479,  629,  661,  670 

Winkler,  51S 

Witzel,  347 

Woakes,  503 

Wolff,  448.  563 

Wolfler,  611 

Wood  (Horatio),  299 


INDEX    OF    NAMES 


Wood  (Walter),  659 
Wright,  251,  258 
Wright  (Jonathan),  572 
Wmiderlich,  188 
Wyeth,  334 
Wyss,  676 


Zeiss,  249,  250 
Ziegler,  226 
Ziehl,  25 
Ziemssen,  621 
Zimmerraann,  46 


INDEX 


Abbe's  intracranial  neurec- 
tomy, 541 
method   of   treating   eso- 
phageal stricture,  623 
Abdomen,  manv-tailed  ban- 
dage for,  401" 
Abdominal  binder,  398 
plaited,  398 
region,  actinomycosis  of, 
211 
Abrasions  of  skin.  67 
Abscess,  11 
acute,  11 
alveolar,  527 
bone,  141 
cerebellar,  462 
cerebral,  462 
chronic,  11 
cold,  11,  141,  152 
cortical,  acute  traumatic, 

456 
hepatic,    ameba    coli    in, 

278 
hot,  11 

in  scar  tissue,  68 
metastatic,  of  gums,  527 
of  l^rain,  460,  586 

chronic  traumatic,  461 
developing    from     dis- 
ease of  skull,  463 
diagnosis,  459 
metastatic,  464 
of  nasal  origin,  463 
otitic,  462 
of    chest,    originating    in 
perforation    of    a   sup- 
purating      cavity       of 
lung, 673 
of  lateral  cervical  region, 

627 
of  lung,  681 
sputum  in,  274 
treatment,  682 
of  tongue,  548 
opening  of,  327 
pointing  of,  12 
retropharyngeal,  646 
stitch,  57 
subpectoral,  654 
subperichondrial,  of  nose, 

509 
subperiosteal,     of    gums, 

527 
subphrenic,  676 
traumatic,  of  brain,  460 
Absorbent  cotton,  63 


Accessory    thyroid    glands, 
mucous  cysts  of,  611 
tragus,  238 
Acetate  of  aluminum,  61 
Acid,  boric,  62 

ointment  of,  62 
carbolic,  60 

poisoning   from,   treat- 
ment, 60 
hydrochloric,    free,    pres- 
ence   of,    in    gastric 
contents,  275 
total    free,    in    gastric 
contents,   test  for, 
276 
in    gastric    contents, 
test  for,  276 
lactic,     presence     of,     in 

gastric  contents,  275 
osmic,   intraneural  injec- 
tions, in  facial  neural- 
gia, 544 
salicylic,  61 
Acidity,    total,    due    to   or- 
ganic acids  and  acid 
salts,  in  gastric  con- 
tents, test  for,  276 
of  gastric  contents,  test 
for,  275 
Acinous        carcinoma        of 

breast,  658 
Acne  pustulosa,  475 

rosacea,  500 
Actinomycosis,  209 
diagnosis,  143,  212 
fluid  obtained  in,  278 
of  abdominal  region,  211 
of  bones,  143 
of  region  of  head,  211 
of  skin,  212 
of  thoracic  region,  211 
pathologic  anatomy,  210 
prognosis,  213 
renal,  urine  in,  270 
Actinomycotic  appendicitis, 
213 
pyemia,  212 
Adams's  saw,  363 
Adenoids,  574 
Adenoma,  coinplex,  231 
cystic,  231 
of  breast,  657 
of  jaw,  532 
of  larynx,  606 
of  lips,  477 
of  liver,  232 

693 


Adenoma  of  parotid  gland, 
591 
of     submaxillary     gland, 

591 
of  sweat-glands,  477 
of  thyroid  gland,  232,  611 
prostatic,  232 
sebaceous,  231 
Adenopathy,  secondary 

lymphatic,  in  syphilis,  195 
Adenosarcoma,  230 
of  breast,  658 
of  parotid  gland,  591 
of     submaxillary     gland, 
591 
Adhesive  inflammation,  8 
plaster,  402 

coaptation  by,  326 
resin,  402 
rubber,  402 
surgeon's,  402 
uses,  402 
Adrenalin    in    hemorrhage, 

343 
Adventitious  bursae,  240 
Agar,  glycerin,  21 

jelly,  method  of  making, 
21 
Air,   aspiration   into   veins, 
98 
embolism  from  injuries  to 

veins,  343 
liquid,  as  anesthetic,  306 
Air-passages,  foreign  bodies 
in,  treatment,  596 
gunshot  wounds  of,  594 
wounds  of,  594 
Albumin  in  urine,  260 

heat  and  nitric  acid  test 

for,  260 
nitric-magnesium  test  for, 

261 
quantitative     determina- 
tion of,  261 
Albuminometer,  261 

Esbach's.  261 
Alkaline   methylene   -  blue 

stain  for  bacteria,  25 
Alligator  forceps,  620 
Allis's  ether  inhaler,  292 
Alopecia,  syphilitic,  198 
Aluminum,  acetate  of,  61 
Alveolar  abscess,  527 

process,  carcinoma  of,  533 
fractures  of,  519 
resection  of,  534 


694 


INDEX 


Alveolar    ]")rocess,    sarcoma 
of,  533 
subperiosteal    cyst    of, 
532 
Amblyopia  in  lesions  of  the 

base,  470 
Amputation,  376 

and  disarticulation,  choice 

l)et\veen,  379 
circular,  377 
drainage  after,  380 
dressing  after,  380 
errors,  common,  381 
general  rules,  379 
hemostasis  in,  3S0 
in  contiguity,  376 
in  continuity,  376 
indications,  376 
methods,  377 
oval,  379 
primary,  377 
sequels,  381 
suture  after,  380 
Amyloid  tumors  of  tongue, 

555 
Anastomosis,   aneurism  by, 
96 
of  tongue,  555 
nerve,  in   intractable   fa- 
cial paralysis,  626 
Anatomic  forceps,  310 

tubercle,  82 
Ancient  dislocations,  150 
Anemia,    influence   on   sur- 
gical prognosis,  253 
Aneson  anesthesia,  306 
Anesthesia,  288 

after  nerve  injury,  117 
asphyxia  in,  303 
chloroform,     acute     car- 
diac    dilatation     in, 
298 
asphyxial        complica- 
tions, 298 
clonic    movements    in, 

298 
dangerous,  298 
effects,  297 
first  stage,  297 
heart  failure  in,  298 
method  of,  295 
second  stage,  297 
syncope  in,  298 
third  stage,  297 
cocain,  304 

in     removal     of     nasal 

polypi,  505 
intraneural  infiltration, 

305 
local  infiltration  meth- 
od, 305 
perineural    infiltration, 
305 
dangerous,    artificial   res- 
piration in,  300 
Laborde's  method, 
300 


Anesthesia,  dangerous,  arti- 
ficial respiration,  Syl- 
vester's method,  300 
intralaryngeal   insuffla- 
tion in,  300 

ether,  after-effects,  296 
bronchitis  after,  296 
close  system,  293 
contraindications,  289 
dangers,  296 
effects,  291 
first  stage,  291 
fourth  stage,  291 
methods  of,  292 
open  system,  292 
pneumonia  after,  296 
pulmonary  edema  after, 

296 
second  stage,  291 
semi-close  system,  294 
third  stage," 291 

ethyl  bromid,  301 

chlorid,  301,  302,  306 

eucain  /?,  305 

examination   of   heart   in 
preparing  for,  290 
of  kidneys  in  preparing 

for,  290 
of  lungs     in     preparing 
for,  290 

in  face  operations,  304 

kelene,  306 

liquid  air,  306 

local,  304 

nausea   and  vomiting  in, 
303 

nirvanin,  306 

nitrous  oxid,  289,  302 

normal     course,    disturb- 
ances of,  303 

orthoform,  306 

precedent,  301 

primary,  301 

spinal,  306 

tropacocain  hvdrochlorid, 
306 

■\aolent  struggling  in,  303 

vomiting   and  nausea  in, 
303 

withholding   food  in   pre- 
paring for,  290 
Anesthetic,  288 

administration     of,     dan- 
gers, 282 

chloroform  as,  289 

in  operative  treatment  of 
harelip,  486 

in  tracheotomy,  599 

indications  for  use,  288 

nitrous  oxid  as,  289 

preperation  of  patient  for, 
290 

selection,  289 

sulfuric  ether  as,  289 
Anesthetizing  outfit,  295 
Aneurism,  94 

acupuncture  in,  348 


Aneurism  and  heart,  liga- 
tion in  continuity  be- 
tween, 346 

arteriovenous,  96 
of  tongue,  555 

by  anastomosis,  96 
of  tongue,  555 

chemical  means  in,  348 

cirsoid,  94 
of  scalp,  433 
of  tongue,  555 

cylindriform,  95 

diagnosis,  97 

digital  and  instrumental 
compression   in,    348 

dilatation,  95 

dissecting,  96 

ergot  in,  349 

etiology,  95 

false,  95,  96 

from  endarteritis,  95 

fusiform,  95 

galvanopuncture  in,  348 

hernial,  96 

Hunter's  operation  for, 
346 

incision  of  sac  and  subse- 
quent ligation,  346 

intrathoracic,  683 

introduction  of  foreign 
bodies  into  cavity  of, 
348      _ 

ligation  in  continuity  for, 
345 

locality  in  influencing  de- 
velopment, 96 

Matas's  operation  for,  346 

needles,  350 

needling  in,  Macewen's 
method,  349 

occurrence,  95 

of  lateral  cervical  region, 
630 

of  scalp,  433 

pathologic  anatomy,  97 

perforating,  hemoptysis 
due  to,  sputum  in,  274 

peripheral  ligation  in,  346 

racemose,  of  scalp,  433 

rupture,  95 

sacciform,  94,  95 

sjmiptoms,  97 

terminations,  97 

traumatic,  96 

treatment,  98,  348 

true,  94,  95 

varicose,  96 
Aneurismal  varix,  96 
Angina,  Ludwig's,  628 
Angioma,  227 

capillary,  of  facial  region, 
477 

of  auricle,  583 

of  larynx,  606 

of  tongue,  555 

plexiform,  228 

venous,  treatment,  334 


INDEX 


695 


Angiosarcoma,  226 

of  rih.s,  67-i 
Ankle  and  foot,  figure-of-S 

bandage  of,  425 
Ankyloglo.ssia,    acquired, 
"549 
congenital,  54S 
Ankylosis,  160 

bonv,    of   cervical   verte- 
brae, 649 
cartilaginous,  160 
false,  160 
fibrous,  151,  160 
osseous,  161 
true,  160 
Anthrax,  78 

bacillus,  30 
Antiphlogistic  measures,  63 
Antipyretic  drugs,  64 
Antipyrin    in    hemoi'rhage, 

343 
Antiseptic  agents,  59 
dressing  of  wounds,  56 
ointments,  62 
treatment  of  wounds,  56 
Antiseptics,  selection  of,  62 
Antitoxin  treatment  of  tet- 
anus, 190 
Antrectomy,  584 
Antrum  of  Highmore,   epi- 
thelioma of,  530 
hydrops  of,  529 
inflammation  of,  528 
malignant  growths   of, 

530 
sarcoma  of,  530 
Anuria  after  operations,  284 
Appendages,  auricular,  493, 

582 
Appendicitis, actinomycotic, 

213 
Arm  and  hand  sling,  417 
Arnold  steam  sterilizer,  53 
Arteria  thyroidea  ima,  600 
Arterial  and  A^enous  hemor- 
rhage, differential  diag- 
nosis, 99 
hemorrhage,     permanent 
arrest,  340.       See  also 
Hemorrhage,  arterial. 
invagination,  341 

Murphj^'s  method,  341 
Arteries,  contusion  of,  85 
diseases  of,  93 
incised  wounds  of,  86 
injuries  of,  85 

in  fracture  of  rib,   672 
lateral  wounds  of,  86 
ligation  of,  89 

in  continuity,  344 

indications,  344 

methods  and  general 

technic,  349 

punctured  wounds  of,  86 

separation    of,    complete 

transverse,  86 
suture  of,  341 


Arteriorrhaphy ,      M  a  t  a  s '  s 

nietliod  for  aneurism,  346 

Arteriovenous  aneurism,  96 

of  tongue,  555 
Arteritis,  93 
chronic,  93 
thrombo-,  93 
Artery,     carotid,     common, 
ligation  of,  632 
external,     ligation     of, 

634 
hemorrhage    from,    ar- 
rest of,  626 
internal,  ligation  of,  635 
femoral,    ligation   of,    for 
elepliantiasis     arabum, 
349 
iliac,  ligation  of,  for  ele- 
phantiasis arabum,  349 
innominate,    ligation    of, 

635 
ligation  of,  changes  which 
blood  undergoes, 
90 
occur  in  vessel,  90 
fate  of  ligature,  91 
function  of  clot,  91 
lingual,    ligation   in   con- 
tinuity, 557 
subclavian,     hemorrhage 
from,  arrest  of,  626 
ligation  of,  636 
vertebral,  ligation  of,  637 
Arthrectomy,  372 
Arthritis,  150,  151 
acute  septic,  152 
chronic,  152 
deformans,  152,  155 
gonorrheal,  etiology,  154 
metastatic,  etiology,  153 
rheumatoid,  152 
tabetic,  154 
tuberculous,  152 

etiology,  154 
uratica,  etiology,  154 
Arthrogenous  contractures, 

159 
Arthropathy,  tabetic,  152 
Arthrospores,  19 
Articulations,     lateral     cer- 
vical,    inflammation     of, 
645 
Artificial    glucose  in  urine, 
inducing,  264 
larynx,        Gussenbauer's, 
Park's        modification, 
609 
respiration   in   dangerous 
anesthesia,  300 
Laborde's  method, 

300 
Sylvester's    meth- 
od, 300 
Asch's  open  scissors,  496 
Ascites,  chylous,  108 
Aseptic  fever,  47 
wounds,  2 


Asphyxia  in  anesthesia,  303 
Asphyxial  complications  in 
chloroform  anesthesia,  298 
Aspirated  fluids,  examina- 
tion, 277 
Aspiration,  319 

and  puncture  in  pleuritic 

effusions,  676 
of  air  into  veins,  98 
Ataxia,  Bruns's  frontal,  468 
Atheroma,  93 
of  breast,  657 
of  Hps,  477 
Atheromatous  cysts  of  neck, 
629 
removal,  334 
degeneration,  93 
Atlas  and  axis,  645 
Atrophic  kidney,  hematuria 

due  to,  272 
Auditory     canal,     external, 
foreign  bodies  in,  579 
meatus,  cartilaginous,  in- 
juries of,  578 
external,     eczema     of, 
581 
furuncle  of,  581 
removal    of    foreign 

bodies  from,  580 
suppuration  of,  581, 
582 
Aural  polypus,  582 

snare,  Wilde's,  582 
Auricle,  angiomas  of,  583 
cervical,  238 

congenital,  237 
deformities  of,  582 
epithelial    carcinoma    of, 

583 
erysipelas  of,  581 
frost-bites  of,  578 
granuloma  of,  582 
inflammation  of,  581 
injuries  of,  578 
lupus  of,  581 
othematoma  of,  578 
Auricular  appendages,  493, 
582 
dermoids,  238 
fistula,  238 

teratomas  of  neck,  629 
Autoepidermic   skin  -  graft- 
ing, 331 
Autoplastic  operations,  328 
Autotransfusion,  353 
Avulsion  of  scalp,  430 
Axilla  and  neck,  figure-of-8 
bandage,  411 


Bacillus,  18 
anthrax,  30 

colon,  infection  of  urinary 
tract  with,  urine  in,  272 
comma,  18 
Klebs-Loffler,  29 
lepra,  31 


696 


INDEX 


Bacillus  of  glanders,  32 
of  Nicolaier,  29 
of  tetanus,  29 
pyocyaneus,  28 
pyogenes  soli,  27 
smegma,  31 
tuherele,  30 

Ziehl-Xeelsen  stain  I'or, 
25 
Bacteria,  IS 
aerobic,  IS 
anaerobic,  18 
color,  24 

culture  methods  for,   20. 
See  also  Culture  meth- 
ods. 
examination     by     micro- 
scope, 25 
identification,  23 
liquefying,  18 
macroscopic  appearances, 

23 
microscopic  appearances, 

24 
nonliquefying,  IS 
occurrence  and  spread,  16 
odor,  24 

pathogenic,  specific,  29 
spread  of,  16 
staining  of,  24.     See  also 
Staining  bacteria. 
Bacteriologic    examinations 
in  diagnosis  and  progno- 
sis, 247 
Bacteriology,  surgical,  17 
Balsam  gauze,  Peruvian,  63 
Bandage,  388 
abdominal,  398 
manv-tailcd,  402 
plaited,  399 
adhesive  plaster,  402.    See 

also  Adhesive  plaster. 
anterior     figure-of-8,     of 

chest,  412 
ascending  single  spica,  of 
groin,  421 
spica,    of   both   groins, 
423 
of  shoulder,  414 
Barton's,  406 

modified,  407 
breast,  399,  414 

doul^le,  414 
capeline,  of  head,  405 
circular,  390 
classification,  388 
coml")inations  of  spiral,  re- 
A-ersed  spiral,  spica,  and 
figure-of-8,  of  foot,  426 
compound,  396 
demi  -  gauntlet,      dorsal, 
420 
palmar,  420 
descending  single  spica,  of 
groin,  422 
spica,   of  both   groins, 
424 


Bandage,  descending  spica, 
of  shovdder,  415 
dimensions,  389 
double  Ijrcast,  414 
eve,  409 
t-,  398 
Esmarch's,  bloodless  ope- 
rations   by    means    of, 
337 
eye,  double,  409 

single,  409 
figure-of-8,  392 

anterior,  of  chest,  412 
of  elbow,  416 
of  foot  and  ankle,  425 
of  hand  and  wrist,  418 
pahiiar        applica- 
tion, 418 
of  head,  neck,  and  ax- 
illa, 409 
of  knee,  424 
of  leg,  427 

of  neck  and  axilla,  411 

posterior,  of  chest,  414 

fixation,  permanent,    394 

flannel,  392 

for    supporting    tampons 

in  anterior  nares,  410 
forehead  and  neck,  406 
and  nose,  406 
and  upper  lip,  406 
four-tailed,  of  jaw,  401 
fronto-occipital,  404 
gauntlet,  421 
general  rules,  389 
Gibson's,  407 
head,  404 
hernia,  401 
many-tailed,  401 

for  abdomen,  401 
materials,  388 
obUque,  390 
of  head,  404 
of  \&w,  407 
occipitofacial,  406 
of  chin,  405 
of  extremities,  411 
of  forehead,  405 
of  trunk,  411 
permanent  fixation,  394 
plaster-of-Paris,   dangers, 
396 
method  of  preparation, 

395 
removable,  395 
remoA^al,  396 
posterior    figure-of-8,    of 

chest,  414 
pressure,  392 
recurrent,  392 
of  foot,  425 
of  head,  404 
of  stump,  393 
retractors,  401 
reversed  spiral,  391 
of  finger,  419 
of  foot,  425 


Bandage,     reversed     sjiiral, 
of  lower  extremity, 
426 
of  upper     extremity, 
41S 
roller,  varieties,  390 
rubber,  393 

use,  393 
scissors,  390 
serpentine,  of  foot,  426 

of  great  toe,  428 
single  eye,  409 

T-,  398 
sling  for  breast,  414 
spica,  392 

ascending,       of      both 
groins,  423 
of  shoulder,  414 
single,  of  groin,  421 
descending,      of      both 
groins,  424 
of  shoulder,  415 
single,  of  groin,  422 
of  foot,  425 
of  great  toe,  427 
of  thumb,  420 
spiral,  390 
of  chest,  411 
of  finger,  419 
of  foot,  424 
T-,  double,  398 
of  chest,  398 
single,  398 
triangle,  of  groin,  401 
uses,  388 
Velpeau's,  415 
Bandaging,   388.     See   also 

Bandage. 
Barbadoes  leg,  84 
Barton's  bandage,  406 

modified,  407 
Basket  strapping  for  skin- 
grafting,  332,  333 
for  ulcers,  71 
Bedsores,  69 

treatment,  72 
Bellocq's  cannula,  498 
Bergmann's  sepsin,  44 
Bifid  tongue,  549 
Bismuth  test  for  glucosuria, 

262 
Bistouries,  309 
Bladder,  care  of,  before  ope- 
ration, 49 
Blandin-Nuhn  gland,  hyper- 
trophy of,  557 
Bleeders,     hemorrhage     in, 
343 
operations     in,     dangers, 
284 
Blepharoplastic   operations, 

494 
BHstering,  64 

Blood,  changes  in,  in  liga- 
tion of  artery,  90 
clot,  function  of,  in  liga- 
tion of  artery,  91 


INDEX 


697 


Blood,  cryoscopy  of,  252, 2G4 
cysts  of  nock,  629 
electric  conductivity,  2G5 
exanunation,  248 

in  acute  lymphatic  leu- 
kemia, 258 
in  carcinoma,  258 
in    chronic    lymphatic 

leukemia,  258 
in     chronic    myelogen- 
ous leukemia,  258 
in    gastric    carcinoma, 

258 
in  gastric  ulcer,  258 
in    Hodgkin's    disease, 

259 
in  jaundice,  258 
in   maUgnant     disease, 

258 
in  pseudoleukemia,  259 
in  sarcoma,  258 
in    scurvy    and    allied 
conditions,  258 
■    in  tuberculosis,  257 

technic,  248 
in  mine,  267 
local  abstraction,  63 
Blood-changes,  significance, 

253 
Blood-corpuscles,  red,  count- 
ing of,  249 
white.     See  Leukocytes. 
Blood-cultures,  252 
Bloodless      operations      by 
means  of  Esmarch's  ban- 
dage, 337 
Blood-plaques,  90 
Blood-pressure,  259 
Blood-serum,     human,      as 

culture-medium,  21 
Blood-vessels,    diseases    of, 
85 
gunshot  injuries  of,  85 
injuries  of,  85 
operations  on,  336 
small,    subcutaneous    in- 
jury of,  87 
Bone  chisel,  363 
curet,  Bruns's,  318 
Voikmann's,  318 
drill,  315 
hyoid,  594 

malar,  luxation  of,  520 
mallet,  364 
Bone-cutting    forceps,    Lis- 

ton's,  317 
Bones,  abscess  of,  141 
actinomycosis  of,  143 
carcinomas  of,   operation 

for,  370 
caries   of,    evidement   in, 

369 
central  sarcoma  of,  145 
chondromas  of,  operations 

for,  370 
coaptation  of,  by  opera- 
tive means,  365 


Bones,  contusion  of,  123 
cranial,    434.        See    also 

Cranial  hones. 
diseases  of,  123 
division  of,  361 
echinococci  of,  operation 

for,  370 
evidement  of,  369 
excavation  of,  369 
fibromas     of,     operations 

for,  370 
hyperplastic  inflammation 

of,  138 
inflammation    of,    opera- 
tions in,  368 
inflammatory      processes 

in,  138 
injuries  of,  123 
long,  gunshot  injuries  of, 

137 
malignant  disease  of,  ope- 
ration for,  370 
nasal,  fractures  of,  495 
of  skull,  434.       See  also 

Cranial  hones. 
operations  on,  361 

after  fractures,  366 
sarcoma  of,  145 
central,  145 
operation  for,  370 
separation  of,  311 
suture  of,  365 
syphilitic     affections     of, 

142 
transplantation  of,  368 
tumors  of,  operations  for, 
370 
Bony  ankj'losis   of   cervical 
vertebrae,  649 
chest  walls,  670 
parts  of  ear,  injuries,  578 
Boric  acid,  62 

ointment,  62 
Bouillon,  Koch's,  method  of 

making,  20 
Brachial  plexus,   stretching 

of,  637 
Brain,  455 

abscess  of,  460,  586 
chronic  traumatic,  461 
developing  from  disease 

of  skull,  463 
diagnosis,  459 
metastatic,  464 
of  nasal  origin,  463 
otitic,  462 
areas,  localization,  466 
base  of,  lesions,  470 _ 
complications  in  injuries 

of  skull,  438 
compression  and  concus- 
sion   of,    differentia- 
tion, 441 
in  fracture  of  skull,  439 
contusion  of,  455 

in  fracture  of  skull,  442 
gliomas  of,  227 


Brain,  hemorrhage,  456 
extradural,  456 
intracerebral,  457 
intraventricular,  457 
sul)arachnoid,  457 
subdural,  457 
injuries,  diagnosis,  457 
laceration  of,  in  fracture 

of  skull,  442 
motor  area  of,  lesions,  467 
parietal  loljes,  lesions,  468 
traumatic  abscess  of,  460 
tumors  of,  465 
wounds  of,  456 
Branchial  cysts,  237,  628 

fistula,  237,  629,  639 
Branchiogenous  carcinoma, 

629 
Breaking  strain  of  principal 

nerves,  357 
Breast,  adenoma  of,  657 
adenosarcoma  of,  658 
atheroma  of,  657 
bandage,  414 
double,  414 
sling  for,  414 
binder,  399 
carcinoma  of,  658 
acinovis,  658 
inoperable,     treatment 

of,  670 
lymphatic     edema     in, 

661 
prognosis,  661 
radical    operation    for, 
662 
prognosis  after,  669 
treatment,  662 
cystocarcinoma  of,  657 
cysts  of,  657 
dermatitis    of,   malignant 

papillary,  658 
ducts     of,    carcinoma   of, 
1  661 

echinococcus  cysts  of,  658 
enchondroma  of,  657 
fibrocystoma  of,  657 
fibroma  of,  657 
fistula  of,  656 
giantlike  growth  of,  657 
interstitial  paradenitis  of, 

655 
lipoma  of,  657 
melanosarcoma  of,  658 
myxoina  of,  658 
neuralgia  of,  657 
sarcoma  of,  658 

cystic,  658 
scirrhus  of,  659 
streptococcal  infection  of, 

656 
tuberculosis  of,  655 
tumors  of,  malignant,  658 
radical  operation  for, 

662 
treatment,  662 
nonmalignant,  657 


698 


IXDEX 


Breast,  tumors  of,  nonmalig- 
nant,  treatment,  670 

Breasts,  supernumerary,  657 

Breatliing,  mouth-,  504 

Bronchitis  after  ether  an- 
esthesia, 296 

Bronchocele,  610 
cystic,  232 

Bronchus,  foreign  bodies  in, 
595 

Brophy's  mouth  speculum, 
559 

Bruns's  cheiloplasty,  483 
frontal  ataxia,  468 
operation  of  osteoplastic 
resection  of  nose,  507 

Bubo,  syphilitic,  197 

Buck's  extension,  403 

BuUet     in    cranial     cavity, 
probing  for,  451 
removal  of,  386 

Bullet    forceps,    Tiemann's, 
387 
T\-ith      spoon  -  shaped 
jaws,  387 
wounds.      See   also    Gun- 
shot injuries. 

Bunion,  241 

Buried  sutures,  323 

Bums,  degree  of,  73 

inflammatory    conditions 

after,  75 
of  first  degree,  73,  75 
of  second  degree,   73,   75 
of  third  degree,  73,  75 
of  tongue,  546 
prognosis,  73 
treatment,  76 

BurreU's  brass  wire  collar, 
647 

Burrow's  modification  of 
Dieffenbach's  method  for 
closing  triangular-shaped 
defect,  329 

Bursa    mucosa    of    cer^'ical 
vertebral  column,  649 
thyrohyoid,  241 
hvdrops  of,  630 

Bursae,  240 

adventitious,  240 
subtendinous,  240 

Bursitis,  164,  241 

Busch's  method  of  rhino- 
plasty, 511 


Cachexia,  pachvdermatous, 
616 

strumipriva,  616 

syphiUtic,  196,  199 

tuberculous,  205 
Cadaver  tubercle,  82 
Calculus,  lacteal,  657 

renal,  irrine  in,  271 

salivary,  588 
Callus,  130 


Callus,  defective  formation, 
131 

definitive,  130 

excessive  formation,  131 

muscle,  121 

provisional,  130 

regeneration  of,  130 

resection  of,  137 

superfluous,  131 
Cancellous  osteomas,  218 
Camiula,  Bellocq's,  497 

Trendelenburg,  534 
Capeline   bandage  of  head, 

405 
Capillary  angioma  of  facial 
region,  477 

hemorrhage,  106 

nevi  of  tongue,  555 
Caput   obstipum,  624,   650. 
See  also  Torticollis. 

succedaneum,  453 
Carbolic  acid,  60 

poisoning,     treatment, 
60 
Carbolized  oil,  62 
Carbuncle,  78 

of  facial  region,  475 
Carcinoma,  2.32 

acinous,  of  breast,  658 

blood  examination  in,  258 

branchiogenous,  629 

coUoid,  233 

degenerative  changes,  233 

dissemination  of,  233 

epithelial,  of  auricle,  583 
of  esophagus,  621 
of  tonsils,  569 

gastric,    blood    examina- 
tion in,  258 

glandular  infection,  233 

infective  properties,  233 

infiltration  of,  232 

metastasis  of,  233 

of  alveolar  process,  533 

of  bone,  operation  for,  370 

of  breast,   658.     See  also 
Breast,  co.rcinoma  of. 

of  cervical  vertebral  col- 
umn, 649 

of  cheek,  481 

of  ducts  of  breast,  661 

of  frontal  .sinuses,  519 

of  glands  of  neck,  631 

of  gum,  482 

of  intestine,  feces  in,  276 

of  jaw,  533 

of  larvnx.  606 

of  lip.s,  479 

cheiloplasty  in,  482 

of  nasopharAmx,  576 

of  neck,  operation  in,  639 

of  ribs,  674 

of  thyroid  gland,  617 

of  tongue,  549.      See  also 
Tongue,  cancer  of. 

squamous  -  celled  ,     234. 
See  also  Epithelioma. 


Carcinomatous   .stricture   of 
esophagus,     treatment, 
623 
ulceration  of  tonsils,  566 
Caries,  138 

necrotic,  of  jaw,  528 

of    bone,    e\idement    in, 

369 
of  ribs,  672 
sicca,  647 

sj'philitic,       of       cranial 
bones,  453 
of  sternum,  674 
tuberculous,   of  sternum, 
674 
Carotid     arterv,     common, 
Hgation'of,  632 
external,     ligation     of, 

634 
hemorrhage    from,    ar- 
rest of,  626 
internal,     ligation     of, 
635 
Cartilages,  loo.se,  218 

thyroid   and   cricoid,   en- 
chondroma  of,  606 
fracture  of,  594 
Cartilaginous  ankylosis,  160 
auditorv  meatus,  injuries 

of,  578 
tumors  of  tongue,  555 
Caseation,  141 
Catarrh,  acute,  of  renal  pel- 
vis, urine  in,  269 
Catarrhal  pharyngitis,  sub- 
acute, 572 
Catgut,  .sterilization  of,  53 
iodin  method,  55 
sterilizing  apparatus  for, 
54 
Catheterization,        ureteral, 
technic      in       examining 
smaU     amounts  of   urine 
as  obtained  by.  266 
Cauterization,  64 

by  means  of  chemic  sub- 
stances, 317 
Cavernous  Ivmphangiomas, 
228 
nevus,  227 

tumors  of  tongue,  556 
treatment,  334 
Cavities  in  lung,  operations 

on,  682 
Cell,  giant-,  13 
Cells,  connecti-\-e-tissue,  or- 
igin of,  during  healing 
of  wounds,  6 
formative,  of  Marchand,  5 
Cellulitis,  er^•sipelatous,  67 
Cementoma,  219 
Cephalhematoma,  87,  453 
Cephalohematocele,  434 
Cerebellar  abscess,  462 
Cerebral  abscess,  462 
Cer\-ical  auricle,  238 
congenital,  237 


INDEX 


699 


Cervical  fistula,  congenital,   | 
237 
median,  236 
nerves,  injuries  of,  625 
plexus,  branches  of,  divi- 
sion of,  625 
stretchins;  of,  63S 
region,  lateral.    See  Neck, 

lateral  region. 
rib,  630,  649 

exostosis  of,  649 
sympathectomy,  640 
vertebrae,  641 

bony  ankylosis  of,  649 
dislocations  of,  643 
flexion,  643 
in  extension,  643 
mechanism  and  vari- 

eties,  643 
rotation,  644 
fracture  of,  641 

laminectomy  in,  642 
resection  of  spine  in, 
642 
injuries    of,    complica- 
tions, 642 
vertebral   column,    bursa 
mucosa  of,  649 
carcinoma  of,  649 
congenital   clefts   of, 

649 
inflammatory     affec- 
tions of,  645 
sarcoma  of,  649 
tumors  of,  649 
Chain  saw,  312,  361,  362 

carrier,  362 
Chain-stitch  suture,  323 
Chancre,  197 
hard,  82 
Hunterian,  82 
of  nipple,  204 
soft,  82 

treatment,  113 
treatment,  83 
Chancroid,  82 

treatment,  113 
Charcot's  joint  disease.  152 
Cheek,  carcinoma  of,  481 
fibroma  of,  477 
fissure  of,  angular,  491 
congenital,  491 
horizontal,  491 
vertical,  491 
lipoma  of,  477 
lymphangiectatic  cysts  of, 
^  477 

retractor,  560 
splitting,     in     cancer     of 

tongue,  553 
tumors  of,  477 
Cheesy  inflammation,  13 

metamorphosis,  13 
Cheiloplastv,  Bruns's,  483 
Est  lander's,  483 
in  carcinoma  of  lips,  482 
Langenbeck's,  483 


Cheiloplasty,  Sandelin's,  483 
Chemic      examinations      in 
diagnosis  and  progno- 
sis, 248 
substances,   cauterization 
by,  317 
Chemise  tampon  in  hemor- 
rhage, 342 
Chemotaxis,  32 
Chest,  652 

abscess  of,  originating  in 
perforation  of  a  suppu- 
rating cavitv  of  lung, 
673 
anterior  figure-of-8  ban- 
dage of,  412 
cavity,     tumors     within, 

683 
foreign  bodies  in,  653 
gunshot  wounds  of,  652 
suppurative     inflam- 
mation after,  653 
plastic  operations  on,  679. 
See  also  Thoracoplasty. 
posterior  figure-of-8  ban- 
dage of,  414 
region,  tumors  of,  673 
soft   parts,   inflammation 
of,  653 
surrounding,  652 
spiral  bandage  of,  411 
suppurative       inflamma- 
tion of,   after  gunshot 
wounds,  653 
T-bandage  of,  398 
walls,  bony,  670 
wounds    of,    hemorrhage 
from,  652 
penetrating,  652 
perforating,  652 
Chevne-Stokes      respiration 
in   fracture   of  skull,  440 
Chiene's  device  for  locating 

fissure  of  Rolando,  467 
Chilblain,  75 
Chin,  bandage  of,  405 
Chisels,  bone,  364 
Macewen's,  317 
mastoid,  585 
Chlorids  in  urine,  263 
Chloroform  anesthesia,  289 
acute     cardiac     dilata- 
tion in,  298 
asphyxial        complica- 
tions, 298 
clonic    movements    in, 

298 
dangerous,  298 
effects,  297 
first  stage,  297 
heart  failure  in,  298 
method,  295 
second  stage,  297 
svncope  in, 298 
third  stage,  297 
inhaler,  Junker's,  296 
physiologic  action,  288 


Chondritis  cribrosa,  151 
granulosa,  151 
pannosa,  151 
Chondroma,  217 

of   bone,    operations    for, 

370 
of  cranial  liones,  454 
of  jaw,  532 
of  nasopharynx,  576 
of  parotid  gland,  590 
of  ribs,  673 
of  sternum,  675 
of  submaxillary       gland, 
590 
Chorditis     vocalis     inferior 

hypertrophica,  599 
Chylous  ascites,  108 

exudates,  278 
Cicatrices,      deforming,     of 

neck,  624 
Cicatricial  contractures,  159 
ectropion,  474 
keloid,  68 
lockjaw,  531 

meloplastic     operation 
for,  494 
stricture     of     esophagus, 

618,  621 
tissue,  abscesses  of,  68 
epithehoma  of,  69 
Cicatrix,  68 
diseases  of,  68 
injury  to,  68 
ulceration  in,  68 
Circular  amputation,  377 

bandages,  390 
Circulation,  collateral,  89 
reestablishment  of,    after 
ligation  of  artery,  92 
Cirsoid  aneurism,  94 
of  scalp,  433 
of  tongue,  555 
Clamp,  Crile's,  345 
Cleft  of  hard  palate,  562 

functional      disturb- 
ances in  newborn 
from,  562 
uranoplasty  in,  564 
of  soft  palate,  559 

staphylorrhaphy    in, 
560 
Clefts,    congenital,   of    cer- 
vical    vertebral     arches, 
649 
Cloacae,  140 

Clonic  movements  in  chloro- 
form anesthesia,  298 
Clot,  blood,    function  of,  in 

ligation  of  artery,  91 
Clover's  ether  inhaler,  293 
Daniels's      modifica- 
tion, 303 
Coaptation      by      adhesive 
plaster,  326 
of     bone     by     operative 
means,  365 
Cocain  anesthesia,  304 


700 


IX  DEX 


Cocain  anesthesia  in  removal 
of  nasal  polypi,  505 
intraneural  infiltration, 

305 
local  infiltration,  305 
perineural    infiltration, 
305 

in  tracheotomy,  599 

solutions,  sterilization  of, 
305 
Cocci,  18 

Coefficient,  urotoxic,  265 
Cohen's  tracheotoinv  tubes, 

601 
Coin  catcher,  Graefe's,  620 
Cold,  effects  of,  73 

excessive,  74 
Cold  abscess,  11,  141,  152 
Collateral  circulation,  89 
Colles'  law,  204 
Collin's    electric    light    re- 
flector, 597 

glass  syringe,  320 
Colloid  carcinomas,  233 
Coloboma  of  eyelids,  492 

palpebrae,  491 
Colon   bacillus  infection  of 

urinarv    tract,    urine    in, 

272 
Comma  bacilli,  18 
Comminuted  fracture,  125 
Compact  osteomas,  218 
Complex  adenomas,  231 
Complicated  fractures,  126 
Concealed  hemorrhage,  88, 

89 
Concussion    of    brain    and 

compression  of  brain,  dif- 
ferentiation, 441 
Condyloma,  198 
Condylomata  lata,  198 
Connective-tissue    cells,  or- 
igin,  during   healing 
of  wounds,  6 
tumors,  216 
Continuous  suture,  323 
Contour  shots,  652 
Contracture,  159 

arthrogenous,  159 

cicatricial,  159 

mj^elogenous,  159 

neurogenous,  159 

of  lower  jaw,  530.       See 
also  Tetanus. 

t endogenous,  159 
Contractured        tendons, 

lengthening,  358 
Contused  wounds,  1 
Contusions  of  arterv,  85 

of  bones,  123 

of  brain,  455 

in  fracture  of  skull,  442 

of  cranial  bones,  434 

of  joints,  146 

of  nerves,  114 

of  scalp,  simple,  429 

of  skin,  66 


Corpora       quadrigemina, 

tumors  of,  469 
Corpus  callosum,  tumors  of, 

469 
Corpuscles,  red,  counting  of, 
249 
white.     See  Leukocytes. 
Corrosive  sublimate,  59 
Cortical  abscess,  acute  trau- 
matic, 456 
Costotome,  678 
Cotton,  absorbent,  63 

batting,  63 
Counting  red  corpuscles  and 

leukocytes,  249 
Cranial  bones,  acute  infec- 
tious     osteomyelitis 
of,  452 
chondroma  of,  454 
contusions  of,  434 
fractures  of,  434 
nontraumatic     inflam- 
mation of,  452 
sarcoma  of.  454 
suppurative   inflamma- 
tion of,  453 
syphilitic  caries  of,  453 
necrosis  of,  453 
osteoma  of,  453 
tuberculous    inflamma- 
tion of,  452 
tumors  of,  453 
pneumatocele,  454 
Craniotabes,  144,  453 

syphilitic,  204 
Creolin,  61 
Cretinism,  relation  of  goiter 

to,  612 
Cretinoid  disease,  616 
Cricoid  and  thyroid  cartil- 
ages, enchondroma  of,  606 
Cricothvroid    larvngotomv, 

602   " 
Crile's  clamp,  345 
Cross-cutting  forceps,  534 
Cross-hit    gunshot    wound, 

167 
Croup  kettle,  602 
Crushing  of  divided  central 

end  of  nerve,  356 
Crutch  paralysis,  115 
Crvoscopv,    apparatus    for, 
265  " 
of  blood,  252,  264 
of  urine,  264 
technic,  265 
Crvptogenic  pvemia,  184 
Culture",  blood"-,  252  ■ 
methods,  20 
agar  jelly,  21 
glycerin  agar,  21 
human    blood  -  serum, 

21 
potato,  21 
Cuneiform  infarctions,  106 
Curet,  Bruns's  bone,  318 
Delatour's  sinus,  58 


Curet,  irrigating,  318 

sharp,  315 

VoLkmann's  bone,  318 

wire,  500 
Cutaneous  horns,  230 
Cutting  forceps,  314 
Cylindriform  aneurism,  95 
Cy.stitis,  acute,  urine  in,  269 

chronic,  urine  in,  269 
Cystocarcinoma    of    breast, 

657 
Cystoma,  239 
Cy.sts,  239 

branchial,  237,  628 

dentigerous,  219 

dermoid,    congenital,    re- 
moval of,  335 

echinococcus,     fluid     ob- 
tained in,  278 

implantation,  236 

lymphatic,  228 

ovarian,  fluid  obtained  in, 
278 

retention,  239 

sebaceous,  231 

.sjmovial,  239 
Cytodiagnosis,  277 


Daxiels's   modiflcation    of 

Clover  ether  inhaler,  303 

Dare        hemoglobinometer, 

249 
Dawbam's     operation     for 
correction  of  nasal  bony 
defects,  512 
Decortication,     puknonarv^, 

679 
Decubitus.     See  Bedsores. 
Definitive  callus,  130 
Degeneration,        atheroma- 
tous, 93 
polycystic,      of      kidney, 
urine  in,  270 
Delatour's  sinus  curet,  58 
Delirium  tremens,  post-ope- 
rative, 285 
Demarcation,  line  of,  75 

suppuration  of,  75 
Demi  -  gauntlet      bandage 
dorsal,  420 
palmar,  420 
Dental  cysts,  220 

ner\-e,     inferior,     neurec- 
tomy of,  542.       See  also 
Neurectomy     of     inferior 
dental  nerve. 
Dentigerous  cysts,  219 
Dermatitis,  malignant  papil- 
lary, of  breast,  658 
Dermoid   cysts,   congenital, 
of  floor  of  mouth, 
593 
removal,  335 
of  scalp,  433 
Dermoids,  235 
auricular,  238 


INDEX 


701 


Dermoids,  lingual,  236 
of  face,  235 
of  labium,  236 
of  rectum,  237 
of  scalp,  235 
of  scrotum,  236 
of  testicle,  236 
of  tongue,  236 
of  trunk,  235 
postrectal,  237 
rectal,  237 
sequestration,  235 
traumatic,  236 
Diabetes  mellitus,  influence 
in  surgical  diagnosis  and 
prognosis,  26S 
Diagnosis,  functional,  263 
Diapedesis,  hemorrhagic,  9 
Diaphysial  resection,  367 
Dieti'enbach's    method    for 
closing   triangular 
shaped  defect,  328 
Burrow's  modification, 
329 
Dilatation,  acute  cardiac,  in 
chloroform    anesthesia, 
298 
aneurisms,  95 
of  esophagus,  621 
in  stricture,  622 
of  heart,  acute,  as  cause 
of    death    after    opera- 
tions, 286 
of  stomach,   acute,  post- 
operative, 284 
thrombosis,  102 
Diphtheria,  wound,  180 
Diphtheritic     inflammation 
of  larynx  and  trachea, 
598 
paralysis,  603 

of  vocal  cords,  603 
tonsillitis,  566 
ulceration      of      anterior 
tracheal  wall,  603 
Diplococci,  18 

of  gonorrhea,  28 
Director,  grooved,  312 
Disarticulation,  376 

and    amputation,    choice 

between,  379 
hemostasis  in,  380 
indications,  376 
methods,  377 
Disinfection  of  dressing  ma- 
terials, 53 
of  gauze,  53 
of  gowns,  53 
of  instruments,  52 
of  sheets,  53 
of  towels,  53 
Dislocation,  148 
ancient,  150 
combined   ^ith   fracture, 

148 
compound,  149 
habitual,  150 


Dislocation,      habitual,      of 
lower  jaw,  526 
of  cervical  vertebrae,  643 
after-treatment,  645 
flexion,  643 
in  extension,  643 
mechanism  and  vari- 
eties, 643 
rotation,  644 
of  lower  jaw,  525 
of  odontoid  process,  645 
primary,  148 
secondary,  148 
Dissecting  aneurism,  96 
Diverticula    of    esophagus, 

621 
Division  of  nerves,  116 

primary  suture  in,  118 
secondary  suture  in ,  1 18 
Doyen's  surgical  engine.  314 
Drainage  after  amputation, 
380 
of  joints,  371 
of  wounds,  56 
Dressing  after  amputation, 
380 
gauze,  method  of  apply- 
ing, 63 
materials,  62 

disinfection  of,  53 
of  wound,  55 
antiseptic,  56 
Drill,  bone,  313 
Fluhrer's,  313 
jeweler's,  365 
Drills,  313 

Dropsy  of  pericardiima,  685 
Dunham's  thermostat,  23 
Dura    mater,    hemorrhages 
from  sinuses  of,   in  frac- 
ture of  skuU,  441 
Dysphagia,  hysteric,  622 


Ear,  578 

bony  parts  of,  injuries  of, 

578 
external,  inflammation  of, 

581 
lobule  of,  lupus  of,  581 
projecting,  583 
speculum,  tubular,  579 
syringe,  580 

tumors  in  region  of,  582 
Ecchondroses,  217 
Echinococcus     cysts,     fluid 
obtained  in,  278 
of  bone,  operation  for, 

370 
of  breast,  658 
of  lung,  683 
of  neck,  630 
Ecraseur,  piano-mre,  315 
Ectasia  of  esophagus,  621 
Ectropion,  cicatricial,  474 
of  eyelids,   operation  for, 
495 


Ectropion,  of  lips,  stomato- 
plastic  operations  for,  494 
Eczema   of    external    audi- 
tory meatus,  581 
Edema,  104 

acute  purulent,  181 
inflammatory,  9 
inflammatory,  of  tongue, 

546 
lymphatic,   in   carcinoma 

of  breast,  661 
malignant,  181 
of  glottis,  598 
Pirogoff's,  181 
pulmonary,     after    ether 

anesthesia,  296 
scrofulous,  of  lips,  477 
Effleurage,  64 

Effusions,      pleuritic,      675. 
See    also    Pleuritic    effu- 
sions. 
Elastic  ligature,  315 
Elbow,  figure-of-8  bandage 
of,  416 
miner's,  241 
Electric      conducti^•ity      of 
urine  and  blood,  265 
light  otoscope,  580 
reflector,  Collin's,  597 
tongue  depressor,  545 
Elephantiasis  arabum,  84 
ligation      of      external 

iUac  in,  349 
removal,  335 
Elevator,  periosteal,  367 
Elliot's    uterine    repositor, 

385 
Elzholz     ruling     of     blood- 
counting  chamber,  250 
Embedded  sections,  instruc- 
tions for  making,  246 
Embolic      distribution      of 
goiter,  612 
gangrene,  94,  106 
infarction,  106 
Embolism,  105 

air,      from      injuries      to 
veins,  343 
Embolus,  infectious,  106 

obstructive,  106 
Emphysema    as    result    of 
fracture  of  rib,  672 
infectious,  182 
Empyema,  675 
chronic,  676 
encysted,  675 
rupturing  into  lung,  spu- 
tum in.  274 
traumatic,  672 
Encephalitis,  458 
Encephalocele,  472 

acquired,  459 
Encephalomeningitis,  456 
Enchondroma,  nasal,  506 
of  breast,  657 
of  thyroid     and     cricoid 
cartilages,  606 


702 


INDEX 


Endangeitis,      tuberculous, 

205 
Endarteritis,        aneurism 
from,  95 

deformans,  93 
Endotheliomas,  229 
Environment,    influence    in 
innocent  tumors,  215 

influence     in     malignant 
tumors,  214 
Epidermal    layer    of    skin, 

formation,  68 
Epilepsy,    Jacksonian,    472 

surgical,  471 
Epiphora,  530 
Epiphysial  separation,    125 
Epiphysitis,  acute,  139 
Epistaxis,  497 
Epithelial  tumors,  229 
Epithelioma,  234 

dissemination,  235 

lymphatic    glandular    in- 
fection in,  234 

of  cicatricial  tissue,  69 
Epulis,  220,  533 

malignant,  220 

operation  for,  370 
Erasion  of  joints,  372 
Erectile  tumor,  227 
Ergot  in  aneurism,  349 
Erysipelas,  177 

bullosum,  177 

erratic  form,  177 

facial,  476 

gangrenous,  177 

nasal,  500 

of  auricle,  581 

of  pharynx,  573 

of  tongue,  548 

phlegmonous,  177 

predisposition  to,  178 

traumatic,  67 

wandering  form,  177 
Erysipelatous   cellulitis,    67 
Erysipeloid,  108,  179 
Erythrocytes,  counting,  249 
Esbach's       albuminometer, 
262 

reagent,  261 
Esmarch's  bandage,  blood- 
less operations  with,  337 
Esophageal  fistula,  623 

forceps,  620 
Esophagectomy,  624 
Esophageotracheal     fistula, 

619 
Esophagitis,  621 
Esophagostomy,  623,  624 
Esophagotome,  Mackenzie's, 

Roe's  modification,  623 
Esophagotomy,       external, 
622,  623 

internal,  622 
Esophagus,  617 

carcinoma    of,  epithelial, 
621 

compression  of,  621 


Esophagus,     dilatation     of, 
621 
in  stricture,  622 
diverticula  of,  621 
ectasia  of,  621 
fibromas  of,  621 
foreign  bodies  in,  619 
gunshot    wounds    of,  617 
incised  wounds  of,  617 
injuries  of,  617 
instrumentation     of,    618 
myxomas  of,  621 
polypi  of,  621 
punctured      wounds     of, 

618 
resection  of,  624 
stricture  of,  621 

Abbe's  method  of  treat- 
ing, 623 
carcinomatous,      treat- 
ment, 623 
cicatricial,  618,  621 
tumors  of,  621 
Estlander's        cheiloplasty, 
483 
thoracoplasty,  679 
Ether    anesthesia,    after-ef- 
fects, 296 
bronchitis  after,  296 
close  system,  293 
contraindications,  289 
dangers,  296 
effects,  291 
first  stage,  291 
fourth  stage,  291 
methods,  292 
open  system,  292 
pneumonia  after,  296 
pulmonary  edema  after, 

296 
second  stage,  291 
semi-close  system,  294 
third  stage,  291 
inhaler,  AUis's,  292 
Clover's,  293 

Daniels's      modifica- 
tion, 303 
physiologic  action,  288 
sulfuric,     as     anesthetic, 
289 
Ethmoiditis,  516 
Ethyl    bromid     anesthesia, 
301 
chlorid    anesthesia,    301, 
302,  306 
tube,  303 

Ware's    apparatus    for 
open    administration 
of,  303 
Eucain  [i  anesthesia,  305 
Evidement  of  bone,  369 
Excavation  of  bone,  369 
Excision  of  goiter,  613 
partial  lateral,  of  larynx, 
609 
Exophthalmic  goiter,  612 
Exostoses,  219 


Exostosis    of    cervical    rib, 
649 
subungual,  219 
Expediency,   operations  of, 
^281 

Exploratory     puncture      in 
diagnosis     of     inflamma- 
tion, 36 
Extension  thrombi,  102 
Extirpation   of  goiter,    613 
of  larynx,  608 
of  parotid  gland,  591 
of     submaxillary     gland, 

591 
of  tumors  of  nerves,  356 
Extremities,    bandages    of, 

411 
Extremity,   lower,   reversed 
spiral  bandage  of,  426 
upper,      reversed      spiral 
bandage  of,  418 
Exudates,  chylous,  278 
examination,  277 
putrid,  278 
Exudative  inflammation,  8 
Eye    bandage,   double,   409 
single,  409 
sarcoma  of,  477 
Eyelids,  coloboma  of,  492 
congenital    anomahes   of, 

492 
ectropion  of,    operations, 

for,  495 
tumors  of,  477 


Face,  dermoids  of,  235 
operations,  anesthesia  in, 

304 
powder  grains  in,  474 
rodent  ulcer  of,  478 
Facial  erysipelas,  476 

nerve,    neurectomy    and 
stretching        of, 
545 
Hueter's    method, 
545 
paralysis     of,     trismus 
associated   with,   188 
neuralgia,  intraneural  in- 
jections of  osmic   acid 
in,  544 
paralysis,         intractable, 
nerA^e  anastomosis  in, 
626 
trismus  associated  with, 
188 
region,  capillary  angioma 
of,  477 
carbuncle  of,  475 
congenital    fistulas    of, 

492 
injuries  of,  474 
lupus  of,  476 
nerves  of,  540 
nevi  of,  477 


INDKX 


703 


Facial    region,    soft     parts, 
474 
nontrauniatic      in- 
ilainmatiou      of, 
47r> 
traumatic    infiam- 
uuition  of,  474 
Facultative  parasites,  IS 
Fasciae,  diseases  of,  120 
inflammation  of,  120 
injuries  of,  120 
Fauces,  566 
^  foreign  bodies  in,  570 
Feces,  examination,  276 
in    intestinal    carcinoma, 
276 
tul)erculosis,  276 
ulcerations,  276 
macroscopic  examination, 

276 
microscopic  examination , 
276 
Female    genitals,     care    of, 

before  operation,  49 
Ferment,  fibrin,  47 
Ferripvrin    in    hemorrhage, 

343" 
Fetal   adenoma   of   thyroid 

gland,  611 
Fibrin  ferment,  47 
Fibroadenoma,  231 
Fibroc3'stoma  of  breast,  657 
Fibroma,  220 

of    bone,    operation    for, 

370 
of  breast,  657 
of  cheek,  477 
of  esophagus,  621 
of  jaw,  532 
of  nasopharynx,  574 
of  scalp,  434 

of  tendons,  removal,  360 
of  tongue,  555 
pediculated,      of     larynx 
and  trachea,  606 
Fibromyoma  of  tongue,  548, 

555 
Fifth  nerve,  neurectomy  of 
second    and    third    divi- 
sions,   with    avulsion    of 
Gasserian  ganglion,  541 
Figure-of-S  bandage.  392 
anterior,  of   chest,  412 
of  elbow,  416 
of  foot  and  ankle,  425 
of  hand  and  wrist,  418 
palmar        appHca- 
tion,  418 
of      head,     neck     and 

axilla,  409 
of  knee,  424 
of  leg,  427 

of  neck  and  axilla,  411 
posterior,  of  chest,  414 
Finger,   spiral   bandage   of, 
419 
reversed,  419 


Firearm  projectiles,  3X6 
Fissure    of   cheek,  angular, 
491 
congenital,  491 
liorizontal,  491 
v(M-ticai,  491 
of   Kolando,   localization, 
407 
('hiciie's    device,  467 
of  soft  palate,  559 
congenital,  559 
of    sternum,     congenital, 
675 
Fistula,  12,  140 
auricular,  238 
branchial,   237,    629,   639 
congenital  cervical,  237 
of  facial  region,  492 
of  neck,  629 
esophageal,  623 
esophageotracheal,  619 
lacteal,  656 
median  cervical,  236 
of  breast,  656 
of  lower  lip,  493 
of  neck,  629 
of  Stenson's  duct,  587 
tracheal,  629 
tuberculous,  207 
Fitch's    dome    trocar    and 

cannula,  319 
Fixation  Isandages,   perma- 
nent, 394 
FlaiHike  joints,  375 
Flannel  bandage,  392 
Flap  amputation,  378 

granulating,   transplanta- 
tion of,  330 
Floating   kidney,    urine   in, 

270 
Fluctuation  in  diagnosis  of 

inflammation,  34 
Fluhrer's  crochet  drill,  313 
Fluids,  aspirated,  examina- 
tion of,  277 
FoUicular    odontomas,    219 
compound,  219 
tonsillitis,  566 
Food,   withholding,  in  pre- 
paring for  anesthesia,  290 
Foot  and  ankle,  figure-of-8 
bandage,  425 
combinations  of  spiral,  re- 
A-ersed  spiral,  spica,  and 
figure-of-8  bandage, 426 
recurrent  bandage,  425 
reversed   spiral   bandage, 

425 
serpentine  bandage,  426 
spica  bandage,  425 
spiral  bandage,  424 
Forceps,  alligator,  620 
intracannular,  602 
anatomic,  310 
bullet,  with  spoon-shaped 

jaws,  387 
cross-cutting,  534 


Forceps,  cutting,  314 

division    of    bone    by, 
364 
esophageal,  620 
hemostatic,  varieties,  340 
Keen's  gouge,  318 
lion-jaw,  373,  539 
liiston's  bone-cutting,  314 
ring-shaped  pile,  310 
rongeur,  314 
sequestrum,  369 
tenaculum,  309 
thumb,  309 
Tiemann's  bullet,  387 
Forehead    and    neck    ban- 
dage, 406 
and  nose  bandage,  406 
and  upper    Hp    bandage, 

406 
bandage  of,  405 
Foreign  bodies,  383 
effects,  383 

in    air-passages,    treat- 
ment, 596 
in  bronchus,  595 
in  chest,  653 
in  esophagus,  619 
in     external     auditory 

canal,  579 
in  fauces,  570 
in  frontal  sinuses,  518 
in  larynx,  595 
in     meatus,     removal, 

580 
in  nose,  499 
in  parotid  duct,  588 
in  pharynx,  570 
in  soft  palate,  558 
in    submaxillary    duct, 

588 
in  trachea,  595 
migration,  383 
palpation    in    diagnos- 
ing, 384 
probes    in    diagnosing, 

384 
removal,  385 
Rontgen   ray   in    diag- 
nosing, 384 
tracheotomy  for,  604 
Forest  moss,  63 
FormatiA-e   cells   of   March- 

and,  5 
Four-tailed  bandage,  401 

for  jaw,  401 
Fowler's  Hnes  of  incision  for 
resecting  ribs  in  pleurec- 
tomy,  681 
Fractional  sterihzation,  20 
Fracture,  124 

after-treatment,  135 
ambulatory       treatment, 

136 
character  of  force,  124 
classification,  124 
comminuted,  125 
comphcated,  126 


704 


INDEX 


Fracture,  compound,  126 
delayed  union,  treatment, 

367 
direction  of  line  of,  125 
dislocation  combined 

with,  148 
division  of  bones  by,  361 
from  direct  violence,  123 
functional       disturbances 

after,  treatment,  136 
green-stick,  125 
impacted,  127 
implantation      of      ivory 

pegs,  368 
incomplete,  125 
mechanism    of    displace- 
ment, 127 
noncommunicat  ing 
wounds  of  skin  in,  126 
of  alveolar  processes,  519 
of  base  of  skull,  436 
of  cer\ical  A'ertebrae,  641 
laminectomy  in,  642 
resection  of  spine  in, 
642 
of  cranial  bones,  434 
of  hyoid  bone,  594 
of  lower  jaw,  520 

interdental  splint  in, 

521 
Matas's  splint  in,  523 
Robert's   method   of 
treating,  523 
of  nasal  bones,  495 
of  odontoid  process,  641, 

645 
of  ribs,  670 
of  skull,  434 

cerebral  complications, 

438 
Cheyne-Stokes  respira- 
tion in,  440 
compound,  443 
compression  of  brain  in, 

439 
contusion   of  brain   in, 

442 
hemorrhages  from  sin- 
uses of  dura  mater  in, 
441 
laceration  of  brain  in, 

442 
pachymeningitis  in,  443 
trephining  in,  447 
indications  for,  448 
of  sternum,  674 
of  thyroid  cartilages,  594 
of  upper  jaw,  519 
operations  on  bones  after, 

366 
overriding  of  fragments, 

127 
perforating,  126 
Pott's,  149 

relations  of  direct  and  in- 
direct force  to,  124 
resection  of,  368 


Fracture,  rotating  displace- 
ment, 127 
seat,  124 
simple,  course  of,  130 

treatment,  133 
spiral,  123 
splintered,  125 
subperiosteal,  125 
ununited,  operations  for, 
367 
Frame  saw,  311,  313,  361 
Freezing  microtome,  246 
French's    combined    hemo- 
static  forceps   and   re- 
tractor, 600 
palate  hook,  499 
Frontal  sinus,  inflammation 
of ,  515.     See  also  Fron- 
tal sinusitis. 
sinuses,  514 

carcinoma  of,  519 
cysts  of,  518 
foreign  bodies  in,  518 
injuries  of,  514 
malignant   growths   of, 

519 
osteoma  of,  518 
polypi  of,  518 
sarcoma  of,  519 
tumors  of,  518 
sinusitis,  515 
chronic,  516 

turbinectomy  in,  517 
Fronto  -  occipital  bandage, 

404 
Frost-bite,  74 

inflammatory    conditions 

after,  75 
of  auricle,  578 
of  first  degree,  74,  75 
of  second  degree,  74,  75 
of  third  degree,  74,  76 
Frozen  sections,  instructions 

for  making,  245 
Functional  diagnosis,  263 
disturbances    after    frac- 
tures, treatment,  136 
Furuncle,  77 

of  external  auditory  mea- 
tus, 581 
Fusiform  aneurism,  95 


G alt's  trephine,  313 
Galvanocautery  loop,  315 
Ganglia,  central,  lesions  of, 

469 
GangUon,  163,  240 

compound,  240 

of  tendons,  removal,  360 

simple,  240 
Gangrene,  10 

after  venous  stasis,   104, 
105 

drv,   after  venous  stasis, 
105 

emboHc,  94,  106 


Gangrene,  hospital,  180 

moist,  after  venous  stasis, 
105 

of  lung,  682 

senile,  93,  106 
Gangrene  foudroyante,  181 
Gangrenous  erysipelas,  177 

inflammation,  8,  10 
suppurative,  10 

pharyngitis,  573 
Gaping  of  wounds,  66,  321 
Gastric.     See  Stomach. 
Gastrotomy,  temporary,  in 

cicatricial  esophageal 

stricture,  622 
Gauntlet  bandage,  421 
Gauze,  disinfection  of,  53 

dressings,  method  of  ap- 
plying, 63 

iodoform,  63 

Peruvian  balsam,  63 
Gelatin,  nutrient,  method  of 

making,  20 
Genitals,    female,    care    of, 

before  operation,  49 
Giant-cell,  13 
Giantlike  growth  of  breast, 

657 
Gibson's  bandage,  407 
Gigli  wire  saw,  312,  361,  362 
Gingivitis,  527 
Glanders,  78 

bacillus  of,  32 

ulceration     of,    in     nose, 
503 
Glioma  of  brain,  227 

of  spinal  cord,  227 
Glossitis,  chronic,  547 
Glottis,  edema  of,  598 
Glucose,    quantitative    esti- 
mation of,  262 
Glucosuria,  262 

artificial,  inducing,  264 

bismuth  test  for,  262 

Haines's  test  for,  262 

Rudisch  quantitative  test, 
262 
Glycerin  agar,  21 
Goiter,  610 

cystic,  611 

embolic  distribution,  612 

enucleation  of,  615 
resection  of,  616 

excision  of,  613 

exophthalmic,  612 

extirpation  of,  613 

fibrous,  calcifying,  611 

growth,  611 

ossifying,  611 

relation  to  cretinism,  612 

resection  of,  615 

vascular,  611 
Golding-Bird  operation   for 

single  harelip,  488 
Gonococcus  of  Neisser,  28 
Gonorrhea,   diplococcus   of, 

28 


INDEX 


705 


Gonorrhoal  arthritis,  15-1 
Gowns,  disint'oction  of,  53 
Graefe's  coin  catcher,  620 
Gram's  stain,  25 
Granny  knot,  340 
Granulating  fhip,  transplan- 
tation of,  330 
intianimation,  12 
proliferative  processes  of 

nose,  509 
synovitis,  151 
wound,  3 
Granulation  tissue,  3 
Granulations,  profuse,  5S 
Granuloma,       hemorrhaa;ic, 
460 
of  auricle,  5S2 
of  tracheal  wound,  603 
tuberculous,  207 
Graves's  disease,  612 
Green-sticlc  fracture,  125 
Groin,  ascending  single  spica 
bandage  of,  421 
descending     single    spica 

bandage  of,  422 
triangle  bandage  of,  401 
Groins,      both,      ascending 
spica  bandage  of,  423 
descending   spica   ban- 
dage of,  424 
Grooved  director,  309 
Gross  pathology  in  diagno- 
sis and  prognosis,  244 
Gumma,  197 
of  skin,  82 

of  subcutaneous    connec- 
tive tissue,  82 
precocious,  198 
svphilitic,    of   sternomas- 
'  toid,  630 
tuberculous,  81 
Gums,  carcinoma  of,  482 
inflammation  of,  527 
lead  poisoning  of,  528 
metastatic  abscess  of,  527 
multiple  pyemia  of,   527 
subperiosteal  abscess  of, 
527 
Gunshot  injuries,  165 
complications,  175 
contour,  652 
cross-hit,  167 
definition,  165 
deformation  of  projec- 
tile, 166 
diagnosis,  173 
general  characteristics, 

165 
hemorrhage,  171 
infection,  173 
lodgment     of     missile, 

r72 
multiplicity,  172 
mushrooming,  166 
of  air-passages,  594 
of  blood-vessels,  85 
of  chest,  652 
46 


Gunshot   injuries   of   chest, 
suppurati\'e    inflam- 
mation  after,   653 
of  esophagus,  617 
of  head,  4^50 

prol>ing     for    bullet, 
451  ' 
of  joints,  147 
of  long  bones,  137 
of  tongue,  546 
pain,  171 
plumbism,  176 
powder  burns,  172 
prognosis,  174 
removal  of  bullets,  175 
seton,  652 

shape  and  size  of  pro- 
jectile, 166 
shock,  171 
symptoms,  171 
treatment,  175 
wound  of  entrance,  166 
of  exit,  168 
Gussenbauer's  artificial 

larvnx.    Park's   modifica- 
tion, 609 
Gynecomastia,  655 


Habitual   dislocation,    150 
Hagedorn  needle,  321 
Haines's  test  for  glucosuria, 

262 
Halsted's  operation  for  car- 
cinoma of  breast,  666 
Hand  and  arm  sling,  417 
and  wrist,  figure-of-S  ban- 
dage of,  418 
palmar     application, 
418 
Hanging,  suicidal,  645 
Harelip,  484 

after-treatment,  490 
choice    of    operation    in, 

488 
double,  disposition  of  in- 
termaxillary     bones 
in  operation  for,  489 
operation  for,  489,  490 
time  for  operation,  489 
first  degree,  485 
functional      disturbances 

in,  485 
operative   treatment,  486 
anesthetic  in,  486 
general  technic,   486 
second  degree,  485 
single,  Golding-Bird  ope- 
ration for,  488 
Malgaigne's     operation 

fo^r,  487 
methods    of    operation 

in,  487 
Mirault    -    Langenbeck 

operation  for,  487 
N^laton's  operation  for, 
487 


Harelip,      single,      Simon's 
operation  for,  488 
third  degree,  485 
Head,  actinomycosis  of  re- 
gion of,  211 
bandages,  404 
capeline  l)andage,  405 
gunshot  wounds,  450 

probing     for     bullet, 
451 
oblique  liandage,  404 
recurrent  l)andage,  404 
surgery,  429 
Healing   bv  primary   inten- 
tion, 2 
by    secondary    intention, 

2,   3      ' 
by  third  intention,  6 
process,  histology  of,  4 
with  suppuration,  3 
without  suppuration,  2 
Heart,  684 

dilatation,  acute,  as  cause 
of  death  after  ope- 
rations, 286 
in    chloroform    anes- 
thesia, 298 
examination    of,    in    pre- 
paring   for    anesthesia, 
290 
failure  in  chloroform  nar- 
cosis, 298 
wounds  of,  684 
Heat    and   nitric    acid   test 
for  albumin  in  urine,  260 
effects  of,  73 
of  inflammation,  7 
Hemarthrosis,  87,  146 
puncture    of    capsule    in, 
370 
Hematoma,  66,  87 

of  scalp,  429 
Hematuria,  267 

due   to   atrophic   kidney, 
272 
Hemianopia  in  lesions  of  the 

base,  470 
Hemocvtometer,       Thoma- 
Zeiss",  249 
Hemoglobin,  estimation  of, 
249 
Dare's  instrument   for, 
249 
scale,  Tallqvist's,  249 
Hemoglobinometer,      Dare, 

249 
Hemophilia,  hemorrhage  in, 
343 
operations     in,     dangers, 
284 
Hemoptysis  due  to  perforat- 
ing aneurism,  sputum  in, 
274 
Hemorrhage,  88 
adrenalin  in,  343 
antipvrin  in,  343 
arrest  of,  336 


ro6 


INDEX 


Hemorrliage,    arrest   of,    by 
digital    compression, 
336 
b}^  forced   positions   of 

joints,  337 
by  pressure   by   means 
of   specially    devised 
apparatus,  337 
provisional    measures, 

336 
spontaneous,  87 
arterial  and  venous,   dif- 
ferential diagnosis,  99 
permanent    arrest,    340 
bv        acupressure, 

"341 
bv     circumsuture, 

"341 
bv      forcipressure, 

"340 
by      invagination, 

341 
by  ligature,  341 
by  suture,  341 
by  torsion,  341 
avoidance    of,    in    opera- 
tions, 282 
capillary,  106 
concealed,  88,  89 
ferripyrin  in,  343 
from   carotid   artery,    ar- 
rest of,  626 
from    sinuses      of      dura 
mater    in    fracture    of 
skuU,  441 
from  subclavian      artery, 

arrest  of,  626 
from    wounds    of    chest, 

652 
graduated    compress    in, 

342 
in  bleeders,  343 
in  hemophiliacs,  343 
in     operations,     dangers, 

284 
intracranial,  456 
extradural,  456 
intracerebral,  457 
intraventricular,  457 
subarachnoid,  457 
subdural,  457 
of  wound,  2 

oil  of  turpentin   in,  343 
parenchymatous,      arrest 

of,  342 
primary,  88 
recurring,  88 

after  operations,  284 
secondary,  87,  88 
spontaneous  arrest,  87 
styptics  in,  343 
subcutaneous,  88 
suturing  in,  deep,  342 
symptoms,  89 
tampon  in,  chemise,  342 
tamponade  in,  342 
treatment,  general,  353 


Hemorrliage,  venous,  98 

and  arterial,  differential 

diagnosis,  99 
arrest  of,  343 
Hemorrhagic  diapedesis,  9 
fever,  89 
granuloma,  460 
Hemorrhoitl  forceps,  310 
Hemostasis  in  amputation, 
380 
in  disarticulation,  380 
prophylactic,  339 
Hemostatic    forceps,    varie- 
ties, 340 
Hemothorax,  624 
Hepatic  abscess,  Ameba  coli 

in,  278 
Hernia  bandage,  401 
cerebri,  459 
of  lung,  684 
Hernial  aneurism,  96 
Herpes  labialis,  476 

rhagades,  476 
Heteroplastic       operations, 

328 
Highmore,   antrum  of,  epi- 
thelioma of,  530 
hydrops  of,  529 
inflammation  of,  528 
malignant   growths   of, 

530 
sarcoma  of,  530 
Histology,     pathologic,     in 
diagnosis   and   prognosis, 
245 
Hodgkin's  disease,  113 

blood    examination   in, 
259 
Hordeolum,  475 
Horns,  cutaneous,  230 

sebaceous,  230 
Hospital  gangrene,  180 
sore  throat,  573 
steam-sterilizer,  53 
Hot  abscess,  11 
Hot-air  sterilizer,  25 
Housemaid's  knee,  241 
Hueter's  method  of  neurec- 
tomy   and    stretching    of 
facial  nerve,  545 
Hunterian  chancre,  82 
Hunter's  operation  for  aneu- 
rism, 346 
Hutchinson  teeth,  204 
Hyahne  thrombi,  106 
Hydrarthrosis,  151 

puncture  of  capsule  in,  370 
Hydrocele  of  neck,  228 
congenital,  628 
noncongenital,  630 
Hydrocephalus,  473 

internal,  470 
Hydrochloric      acid,      free, 
presence   of,   in   gas- 
tric contents,  275 
total  free,  in  gastric  con- 
tents, test  for,  276 


Hydrocliloric  acid,  total,  in 
gastric  contents,  test  for, 
276 
Hydronephrosis,    fluid    ob- 
tained in,  278 
urine  in,  270 
Hydrophobia,  190 
inoculation  test,  192 
Pasteur's  prophylactic  in- 
oculation, 192 
Hydrophobic    tetanus,    188 
Hydrops  of  antrum  of  High- 
more,  529 
of  thyrohyoid  bursa,  630 
tuberculous,  151 
Hydrothorax,  675 
Hygroma,  congenital  cystic, 

of  neck,  629 
Hyoid  bone.  594 

fractures  of,  594 
Hyperplasia,  congenital,  of 
hps,  477 
ftukemic,     of     lymphatic 

glands,  113 
syphilitic  renal,   simulat- 
ing malignant  growth, 
urine  in,  270 
Hyperplastic  inflammation, 
8 
in  bone,  138 
polypan  arthritis,  155 
synovitis,  151,  155 
papillary,  155 
Hypertrophic  rhinitis, 

chronic,  502 
tonsiintis,  566 

tonsillotomy  in,  567 
Hypertrophy     of     Blandin- 
Nuhn  gland,  557 
of  hTnphatic   glands,  pro- 
gressive multiple,  113 
of  thyroid  gland,  611 
Hypodermoclysis,  352 
Hypoglossal  nerve,  injuries 

of,  625 
Hysteric  dysphagia,  622 


Ice,  local  use,  63 
Ice-coil,  64 

Ichthyosis  of  tongue,  547 
Iliac  artery,  external,  liga- 
tion  of,    in   elephantiasis 
arabum,  349 
Impacted  fracture,  127 

treatment,  133 
Imperative   operations,  280 
Implantation  cysts,  236 
Incised  wounds,  1 
of  arteries,  86 
of  esophagus,  617 
of  tendons,  122 
of    venous    trunks    of 
neck,  627 
Incision    and    drainage    of 
joints,  371 
in  pleuritic  effusions,  677 


INDEX 


707 


Incomplete  fracture,  125 
Inculiator,  laboratory,  23 
Infarction,    cuneiform,    106 

eml)olic,  106 
Infectious  embolus,  106 

emphysema,  182 

osteomyelitis,     acute,     of 
cranial   bones,  452 
of  jaw,  528 

sinus  thrombosis,  464 
Inflammation,  1 

adhesive,  S 

after  injuries  of  scalp,  431 

cheesy,  13 

diagnosis,  33 

difterential  count  of  leu- 
kocytes in,  253 

diphtheritic,  of  larynx  and 
trachea,  598 

etiolog}^  14 

exploratory  puncture  in 
diagnosis  of,  36 

exudative,  S 

fever  in,  36 

fluctuation  in,  34 

gangrenous,  S,  10 

granulating,  8,  12 

heat  in,  7 

hyperplastic,  8 
in  bone,  138 

in  general,  8 

in  lateral  cer\'ical  region, 
627 

inspection  in  diagnosis  of, 
33 

loss  or  impairment  of 
function  in,  38 

mensuration  in  diagnosis 
of,  36 

nontraumatic,  of  cranial 
bones,  452 
of  soft   parts   of   facial 
region,  475 

of  antrum  of  Highmore, 
528 

of  auricle,  581 

of  bone,  operations  in, 
368 

of  covering  of  nose,  500 

of  external  ear,  581 

of  fasciae,  120 

of  frontal  sinus,  515.  See 
also  Frontal  sinusitis. 

of  gums,  527 

of  joints,  150.  See  also 
Arthritis. 

of  lateral  cer-\-ical  articu- 
lations, 645 

of  hinph  vessels,  108.  See 
also  Lymphangitis. 

of  lymphatic  glands,  109. 
See  also  Lymphadeni- 
tis. 

of  medullary  tissues,  139 

of  mucous  membrane  of 
nose,  502 

of  muscles,  121 


Inflammation  of  nerves,  118. 

See  also  Neuritis. 
of  pharynx,   572.  See 

also  Pharyngitis. 
of  salivary  gland,  589 
of  soft  palate,  558 

parts  of  chest,  653 
of     tendons,     treatment, 

123 
pain  in,  8,  38 
palpation  in  diagnosis  of, 

33 
periarticular,   158 
phlegmonous,  11 

subpectoral,  654 
probe  in,  36 
productive,  8 
prognosis,  38 
purulent,  8 
redness  of,  7 
regenerative,  8 
septic,    after    operations, 

285 
serofibrinous,  8,  9 
serohemorrhagic,  8,  9 
serous,  8 
suppurative,  8,  10 

gangrenous,  10 

in  sheaths  of  tendons, 
359 

of  chest,  after  gunshot 
wounds,  653 

of  cranial  bones,  453 

of  skin,  67 

of    subcutaneous    con- 
nective tissue,  67 
swelling  of,  7 
symptoms,  objective,  33 

subjective,  37 
termination,  38 
traumatic,  of  soft  parts  of 

facial  region,  474 
treatment,  48 

constitutional,  64 

preventive,  48 
tuberculous,     of     cranial 

bones,  452 
Inflammatory   affections  of 

cervical   vertebral    col- 
umn, 645 
conditions      after     burns 

and  frost-bite,  75 
edema,  9 

of  tongue,  546 
necrosis  of  fasciae,  120 
obstruction  of  larynx  and 

trachea,  598 
processes  in  bone,  138 
tumor,  .590 
Infraction,  125 
Infraorbital  nerves,  neurec- 
tomy of,  540 
Infrathvroid    tracheotomy, 

600 
Infusion,  intravenous  saline, 

351 
subcutaneous,  351 


Inhaler,  AUis's  ether,  292 
Clover's  ether,  293 

Daniels's      modifica- 
tion, 303 
Junker's    chloroform,  296 
Ormsljy's,  294 

Initial  lesion  of  svphihs,  82, 
197 

Injuries     and     diseases     of 
separate  tissues,  66 
gunshot,   165.       See  also 
Gunshot  injuries. 

Innervation,   in.sensible,   45 

Innominate  artery,  hgation 
of,  635 

Insensible  innervation,  45 

Instrumentation  of  esoph- 
agus, 618 

Instruments,  disinfection  of, 
52 

Insufflation,  intralaryngeal, 
in  dangerous  anesthesia, 
300 

Intercostal   arteries,   injury 
of,   in   fracture   of   rib, 
672 
nerves,  neuralgia   of,  673 

Interdental  splint  in  frac- 
tures of  lower  jaw,  521 

Intermuscular  lipomas,  217 

Interrupted  suture,  321 

Intestinal  tuberculosis,  feces 
in,  276 
ulcerations,  feces  in,  276 

Intestine,  carcinoma  of, 
feces  in,  276 

Intra  -  arterial  thrombosis, 
93 

-Intracannular  alligator  for- 
ceps, 602 

Intracuticular  suture,  323 

Intracvstic  villous  papil- 
lomas, 230 

Intramuscular  lipomas,  217 

Intraneural  injections  of  os- 
mic  acid  in  facial  neural- 
gia, 544 

Intraspinal  nerve  stretch- 
ing, 638 

Intrathoracic  aneurism,  683 

Intravenous  saline  infusion, 
351 

Intubation  of  larynx,  604 
dangers,  606 
precautions,  606 
removal   of    tube,    605 

Invagination,    arterial,    341 
Murphy's  method,  341 

Involucrum,  140 

lodin  method  of  sterilizing 
catgut,  55 

Iodoform.  61 
gauze,  63 
poisoning,   treatment,   61 

lodophilia,  257 

lodophilic  reaction  of  leuko- 
cytes, 252 


708 


INDEX 


Irrigating  curet,  318 

Ivory  pegs,  implantation  of, 
in  pseudarthrosis  follow- 
ing fracture,  36S 


Jacksonian  epilepsy,  472 
Jarvis's  snare,  504 
Jaundice,    blood    examina- 
tion in,  258 
Jaw,  519 

adenomas  of,  532 
benign  tumors  of,  531 
carcinoma  of,  533 
caries  of,  necrotic,  528 
chondromas  of,  532 
fibromas  of,  532 
four-tailed     bandage     of, 

401 
lower,     acute     infectious 
osteomyelitis  of,  528 
contracture      of,      530. 

See  also  Tetanus. 
dislocation  of,  525 

habitual,  526 
fractures  of,  520 

interdental  splint  in, 

521 
Matas's  splint  in,  523 
Roberts's  method  of 
treating,  523 
habitual  dislocation  of, 

526 
median    section    of,    in 
cancer  of  tongue,  553 
modified  Barton's  ban- 
dage for,  407 
resection  of,  534 
entire,  537 
half,  535 
lumpy,  211 
necrosis  of,  528 

phosphorus,  528 
oblique   bandage   of,  407 
odontomas  of,  532 
osteomas  of,  532 
osteomyelitis  of,  acute  in- 
fectious, 528 
periostitis  of,  suppurative, 

527 
sarcoma  of,  532 
tumors  of,  benign,  531 

mahgnant,  532 
upper,   fractures    of,    519 
resection  of,  537 
Jeweler's  drill,  365 
Joint  disease,  Charcot's,  152 
Joints,  contracture  of,  159. 
See  also  Contracture. 
contusions  of,  146 
diseases  of,  146 
drainage  of,  371 
erasion  of,  372 
flail-Uke,  375 
gunshot  wounds  of,  147 
incision  and  drainage  of, 
371 


Joints,  inflammation  of,  150. 
See  also  Arthritis. 
injuries  of,  146 
movable  bodies  in,  162 

treatment,  376 
operations  on,  370 
after  injury,  370 
resection  of,  371 

after-treatment,  374 
for    tuberculous    mye- 
Htis,   374 
synovitis,  374 
general  technic,  373 
immediate,  372 
intermediate,  372 
partial,  372 
primary,  372 
secondary,  372 
subcapsular,  373 
subperiosteal,  373 
sarcoma     of,     treatment, 

376 
wounds  of,  147 
Jugular  A'ein,   external,   in- 
juries of,  627 
Junker's  chloroform  inhaler, 

296 
Jury  mast,  647 
Jute,  63 


Keen's  gouge  forceps,  318 
Kelene  anesthesia,  306 
Keloid,  cicatricial,  68 
Kettle,  croup,  602 
Kidney,    actinomycosis    of, 
urine  in,  270 
atrophic,    hematuria    due 

to,  272 
calculus  in,  urine  in,  271 
cysts  of,  urine  in,  270 
examination    of,    in    pre- 
paring   for    anesthesia, 
290 
floating,  urine  in,  270 
hyperplasia,  of   syphilitic, 
simulating       malignant 
growths,  urine  in,  270 
malignant      tumors      of, 

urine  in,  270 
parenchyma     of,    pyelitis 
with  hyperemia  of,  urine 
in,  269 
pelvis  of,  acute  catarrh  of, 

urine  in,  269 
polycystic      degeneration 

of,  urine  in,  270 
subcutaneous  traumatism 

of,  urine  in,  272 
tuberculosis   of,    urine   in, 
271 
Klebs-Loffler  bacillus,  29 
Knee,    figure-of-8    bandage 
of,  424 
housemaid's,  241 
Kocher's  curved  incision  for 
goiter,  613 


Kocher's  operation  for  can- 
cer of  tongue,  554 
for  torticollis,  651 
Koch's  bouillon,  method  of 

making,  20 
Konig's  osteoplastic  rhino- 
plasty, 513 
rhinoplasty,  511 
Kronlein's        craniocerebral 

topographic  hues,  463 
Kyphosis,  646 


Labium,  dermoids  of,  236 
Laboratory     aids     in     sur- 
gical diagnosis  and  prog- 
nosis, 243 
incubator,  23 
Laborde's   method  of  trac- 
tion of  tongue  in  danger- 
ous anesthesia,  300 
Lacerated  wounds,  1 

of  tongue,  546 
Laceration  of  brain  in  frac- 
ture of  skull,  442 
Lacteal  calculi,  657 

fistula,  656 
Lactic  acid,  presence  of,  in 

gastric  contents,  275 
Laminectomy  in  fracture  of 

cervical  vertebrae,  642 
Langenbeck's     cheiloplasty, 
483 
osteoplastic    resection    of 
nose,  507 
Laryngeal  nerve,  recurrent, 
injuries  of,  625 
paralysis     of,     after 
thyroidectomy,  617 
stenosis,  607 
Laryngectomy,  608 
mortality  from,  610 
partial,  609 
Laryngitis,  syphilitic,  599 
tuberculous,  599 
typhoid,  599 
variolous,  599 
Laryngofissure,  608 
Laryngoscopy,  596 
Laryngotomy,  599,  607 

cricothyroid,  602 
Laryngotracheotomy,     599, 

600,  602 
Larynx,  594 

adenoma  of,  606 
angioma  of,  606 
artificial,    Gussenbauer's, 
Park's  modification,  609 
carcinoma  of,  606 
diphtheritic  inflammation 

of,  598 
enchondroma  of,  606 
excision  of,  partial  lateral, 

609 
extirpation  of,  608 
fibromas  of,  pediculated, 
606 


INDEX 


709 


I>ar\iix,    I'orc'i.iin    Ixidics    in, 

infiainniatory  obstruction 

of,  59S 
injuries  of,  subcutaneous, 

594 
intubation  of,  604 
(lanii'tTS,  606 
precautions,  606 
removal  of  tube,  605 
myxoma  of,  606 
papilloma  of,  606 
sarcoma  of,  606 
stab  wounds  of,  595 
stenosis  of,  607 
suicide  wounds  of,  595 
tumors  of,  606 
Laudable  pus,  3 
Lavage  of  stomach,  618 
Law,  Colles',  204 
Layer  suture,  323 

removable,     323,     324, 
325 
Lead    poisoning    of    gums, 

528 
Leg,  Barbadoes,  84 

figure-of-8     bandage     of, 
427 
Leontiasis,  84,  477 
Lepra  bacillus,  31 

rubra,  S3 
Leprosy,  83 
Leukemia,  113 

acute     lymphatic,     blood 

examination  in,  258 
chronic  lymphatic,  blood 
examination  in,  258 
myelogenous,  blood  ex- 
amination in,  258 
lymphatic,  632 
Leukocytes,  counting,  249 
differential  count,  251 

in  inflamination,  253 
iodophilic  reaction,  252 
microscopic    examination 
of    stained    specimens, 
251 
Leukocytosis,  253 
Leukokeratosis,  547 
Leukoplakia,  547 
Ligation   in   continuity   be- 
tween aneurism  and 
heart,  346 
for  aneurism,  345 
in  neoplasms,  349 
of  artery,  344 
indications,  344 
methods   and   general 
technic,  349 
of  lingual  artery,  557 
of  veins,  351 
multiple,  of  veins,  351 
of  artery,  89 

changes     which     blood 
undergoes,  90 
which  occur  in  ves- 
sel, 90 


Ligation  of   artery,   fate  of 
ligature,  91 
function  of  clot,  91 
in  continuity,  344 
indications,  344 
methods  and  general 
technic,  349 
of  common  carotid  artery, 

632 
of  external     carotid     ar- 
tery, 634 
of  external  iliac  artery  in 
elephantiasis      arabum, 
349 
of   femoral  artery  in  ele- 
phantiasis arabum,  349 
of  innominate  artery,  635 
of  internal  carotid  artery, 

635 
of  subclavian  artery,  636 
of  vertebral  artery,  637 
peripheral,    in    aneurism, 
346 
Ligature,  elastic,  315 

fate  of,  in  ligation  of  ar- 
tery, 91 
lateral,  of  veins,  343 
material,  340 

sterilization  of,  53 
Line  of  demarcation,  75 
Lingual   artery,   ligation   in 
continuity,  557 
dermoids,  236 
nerA'e,  neurectomy  of,  544 
Lion-jaw  forceps,  373,  539 
Lipoma,  216 

intermuscular,  217 
intramuscular,  217 
meningeal,  217 
of  breast,  657 
of  cheek,  477 
of  scalp,  434 
of  tongue,  555 
periosteal,  217 
subcutaneous,  216 
submucous,  216 
subserous,  216 
subsynovial,  216 
Lips,  adenoma  of,  477 
atheroma  of,  477 
carcinoma  of,  479 

cheiloplasty  in,  482 
congenital  hyperplasia  of, 
477  • 
malformations   of,    484 
ectropion  of,  stomatoplas- 
tic   operations  for,  493 
fistula  of,  493 
mucous  cysts  of,  477 
scrofulous  edema  of,  477 
tumors  of,  477 
Liquid  air  anesthesia,  306 
Liston's    bone-cutting    for- 
ceps, 314 
Liver,  adenomas  of,  232 
Lizar-Velpeau    incision    for 
simultaneous  removal  of 


both     superior    nuixillas, 

539 
Localization  of  brain  areas, 

466 
Lockjaw,     530.       See     also 

Tetanus. 
Lordosis,  646 
Liicke's       neurectomy       of 

superior  maxillary  nerve, 

540 
Ludwig's  angina,  628 
Lumbar  puncture,  278 
Lumen  of  vein,  obliteration 

of,  103 
Lumpy  jaw,  211 
Lungs,  681 

abscess  of,  681 
sputum  in,  274 

cavities  in,  operations  on, 
682 

echinococcus  of,  683 

empyema  rupturing  into, 
sputum  in,  274 

examination  of,  in  pre- 
paring for  anesthesia, 
290 

gangrene  of,  682 

hernia  of,  684 

neoplasm  of,   sputum  in, 
274 

resection  of,  683 

sarcoma  of,  683 
Lupous    ulceration    of    ton- 
sils, 566 
Lupus  exedens,  80 

exfoliatus,  80 

hypertrophicus,  80 

of  auricle,  581 

of  facial  region,  476 

of  lobule  of  ear,  581 

of  nose,  501 

of  tongue,  548 

vulgaris,  80 
Luxation  of  malar  bone,  520 
Lymphadenitis,  109 

of  lateral  cerAdcal  region, 
627 

septic,  of  lateral  cervical 
region,  628 

syphiUtic,  113 

tuberculous,  111 

of    lateral    cer^dcal   re- 
gion, 627  _ 
Lymphangiectasis,  congeni- 
tal, of  neck,  629 
Lymphangiectatic   cysts   of 

cheek,  477 
Lymphangioma,  228 

cavernous,  228 

congenital,  of  neck,  629 

of  tongue,  228,  548,  556 
Lymphangitis,  108 

reticular,  108 

tubular,  108 
Lymphatic  adenopathy,  sec- 
ondary, in  syphilis,  195 

cysts,  228 


710 


INDEX 


Lymphatic  edema  in  carci- 
noma of  breast,  661 
glands,  diseases  of,  107 
inflammation    of,    109. 
See    also   Lymphade- 
nitis. 
injuries  of,  107 
leukemic      hyperplasia 

of,  113 

progressive        multiple 

hypertrophy  of,  113 

tuberculous,     of    neck, 

extirpation  of,  638 

leukemia,  632_ 

acute,   blood   examina- 
tion in,  258 
chronic,    blood    exami- 
nation in,  258 
nevi,  228 

vessels,  diseases  of,  107 
inflammation    of,    108. 
See    also    Lymphan- 
gitis. 
injuries  of,  107 
Lymphoma,  malignant,  113 
of  nasopharynx,  574.     See 

also  Adenoids. 
of  neck,  632 
Lymphorrhagia,    subcutan- 
eous, 107 
Lymphosarcoma,  222 
Lymphostasis,  109 


Macewen's  chisels,  317 

needling  in  aneurism,  349 
Mackenzie's   esophagotome. 

Roe's  modification,  623 
Macroglossia,  491,  548 
Macrostoma,  491 

stomatoplastic     operation 
for,  493 
Macular  syphilide,  197 
Malar  bone,  luxation  of,  520 
Malgaigne's     operation    for 

single  harelip,  487 
Malignant  disease,  blood  ex- 
amination in,  258 

edema,  181 
Mallet,  bone,  363 
Mamma.     See  Breast. 
Many-tailed  bandage,  401 

for  abdomen,  402 
Marasmus  thrombosis,  102 
Marchand's  formative  cells, 

5 
Massage,  64 

a  friction,  64 
Mastitis  adolescentium,  655 

chronic,  655 

in  male,  655 

nonsuppurative,  654 

of  newborn,  654 

suppurative,  655 
Mastodynia,  657 
Mastoid  chisels,  585 

steatomas  of,  586 


Mastoid,  trephining,  584 
Mastoiditis,  583 
Matas's  operation  for  aneur- 
ism, 346 
splint     in     fractures     of 
lower  jaw,  523 
Maxilla.     See  Jaw. 
Maxillary    nerve,    superior, 
neurectomy      of, 
540 
by    temporary   re- 
section of  malar 
bone,  540 
resection  of,  540 
McBurney's  skin-stretching 

hooks,  332 
Meatus,   auditory,   cartilag- 
inous, injuries  of,  578 
external,  eczema  of,  581 
furuncle  of,  581 
removal     of    foreign 

bodies  from,  580 
suppuration  of,   581, 
582 
Mediastinitis,  anterior,  674 

suppurative,  628 
Medulla  oblongata,   tumors 

of,  470 
Medullary    tissues,    inflam- 
mation of,  139 
Melanosarcoma    of    breast, 

658 
Melanotic       sarcoma,       re- 
moval, 335 
Meloplastic  operation,  494 
for  cicatricial  lockjaw, 

494 
Schimmelbusch's,  494 
Meningeal  lipomas,  217 
Meningitis,  traumatic,  457 
Mensuration  in  diagnosis  of 

inflamrpation ,  36 
Mercuric  chlorid,  59 

iodid,  60 
Metacarpal  saw,  361,  362 
Metamorphosis,  augmented, 
and  surgical  fever,  re- 
lations, 43 
cheesy,  13 
Meyer's   operation   for   car- 
cinoma of  breast,  663 
Microorganisms,  occurrence 

and  spread,  16 
Microscopic  examination  of 
bacteria,  25 
of  stained  specimens  of 

leukocytes,  251 
of  urine,  263 
Microsporon  septicum,  15 
Microstoma,  477 

stomatoplastic  operations 
for,  493 
Microtome,  freezing,  246 
Migration  of  foreign  bodies, 

383 
Mimic  spasm,  545 
Miner's  elbow,  241 


Mirault-Langenbeck    opera- 
tion for  single  harehp,  487 
Mirror,  laryngoscopic,  596 
Moist  gangrene  after  venous 
stasis,  105 
tubercles,  198 
Moiterseur's  pressure  regu- 
lator, 24 
Moles,  238 

Molluscum  fibrosum,  226 
Monoplegia,  468 
Monospasm,  468 
Mosquito,     Thatcher,     253, 

266 
Moss,  forest,  63 

peat,  63 
Motor  area  of  brain,  lesions, 

467 
Mouth,  care  of,  before  ope- 
ration, 49 
dermoid  cysts  of,  593 
speculum,  Brophy's,  559 
Mouth-breathing,  504 
Mouth-gag,  rack-and-pinion, 

564 
Movable  bodies  in  joints,  162 

treatment,  376 
Mucocele,  516 

Mucous   cysts   of   accessory 
thyroid  glands,  611 
of  Hps,  477 
membrane,    sarcomas   of, 
224 
of  nose,  inflammations 
of,  502 
tumors  of,  503 
ulceration  of,  503 
tracheal,  rupture  of,  595 
patches    of    acquired    sy- 
philis, 197 
Multiple      hypertrophy      of 
lymphatic  glands,  pro- 
gressive, 113 
ligation  of  veins,  351 
neuromas,  226 
operations,  281 
pyemia  from  suppurative 
periostitis  of  jaw,  527 
Murphy's  method  of  arter- 
ial invagination,  341 
Muscle  -  fiber,   involuntary, 

sarcomas  of,  122 
Muscles,  callus  of,  121 
diseases  of,  120 
inflammation  of,  121 
injuries  of,  121 
of  neck,  sarcoma  of,  630 

tumors  of,  630 
operations  on,  357 
sternomastoid,  rupture  of, 
624 
syphilitic    gummas    of, 
630 
suture  of,  357 
voluntary,    sarcomas    of, 
121 
Mushrooming,  166 


INDEX 


711 


Myelitis,  acute  suppurative, 
treatment,  369 

granular,  of  ribs,  672 

granulosa,  141 

tuberculous,    resection   of 
joints  for,  37-1 
Myelogenous     contractures, 
159 

leukemia,   chronic,   blood 
examination  in,  258 
Myeloma,  221 
Myoma,  229 

of  neryes,  remoyal,  356 
Myosarcoma,  222 
Myositis,  121 

ossificans,  121 

suppuratiye,  121 
Myotomy,  360 
M^'xedema,  616 
Myxofibroma    of    nasopha- 
rynx, 575 
M}^oma,  221 

of  breast,  658 

of  esophagus,  621 

of  larynx,  606 


Nares,    anterior,    bandage 
for    supporting    tampons 
in,  410 
Nasal    bones,    fractures    of, 

495 
cayities,  soft  parts,  495 
electric    light    speculum, 

498 
septum,  deviations,  496 
speculum,  498 
Nasopharynx,  566 
carcinoma  of,  576 
chondroma  of,  576 
fibroma  of,  574 
lymphoma  of,  574.       See 

also  Adenoids. 
myxofibroma  of,  575 
operations  for  gaining  ac- 
cess to,  for  removal  of 

tumors,  577 
sarcoma  of,  576 
tumors  of,  574 
Nausea    and    vomiting     in 

anesthesia,  303 
Nearthrosis,  375 
Necessity,  operations  of,  280 
Neck  and  axilla,  figure-of-8 

bandage  of,  411 
carcinoma    of,    operation 

in,  639 
cicatrices    of,     deforming, 

624 
cvsts  of,  atheromatous,629 
"  blood,  629 
deforming    cicatrices    of, 

624 
echinococci  of,  630 
fistula  of,  congenital,  629 
glands  of,   carcinoma  of, 

631 


Neck,  glands  of,  removal,  638 
sarcoma  of,  632 
hydrocele  of,  228 
congenital,  628 
noncongenital,  630 
hygroma     of,     congenital 

cystic,  629 
lateral  region,  624 
abscess  of,  627 
aneurism  of,  630 
inflammations  in,  627 
lymphadenitis  of,  627 
paradenitis  of,  628 
septic  lymphadenitis 

of,  628 
spondylitis  in,  646 
tuberculous     lymph- 
adenitis of,  627 
lymphangiectasis  of,  con- 
genital, 629 
lymphangioma    of,     con- 
genital, 629 
lymphatic  tumors  of,  631 
lymphomas  of,  632 
muscles    of,    sarcoma    of, 
630 
tumors  of,  630 
operation  wounds  of,  624 
sarcoma  of,  operation  in, 

639 
skin  of,  tumors  of,  630 
surgery,  594 
teratoma      of,     auricular, 

629 
tumors  of,  cystic,  628 
hTTiphatic,  631 
operations  for,  638 
venous  trunks  of,  incised 

wounds  of,  627 
vessels     of,     injuries    of, 
626 
tumors  of,  630 
Necrosis,  138 

inflammatory,  of   fasciae, 

120 
of  hard  palate,  562 
of  jaw,  528 
of  tendon,  122 
phosphorus,  of  jaw,  528 
syphilitic,       of       cranial 

bones,  453 
tuberculous,  138 
Necrotic  caries  of  jaw,  528 
Needle,  Hagedorn,  321 
Needle-holder,Richter's,  322, 

323 
Needle-holders,  322 
Needles,  aneurism,  350 
Needling  in  aneurism,  349 
Neisser,  gonococcus  of,  28 
Nelaton's  operation  for  sin- 
gle harelip,  487 
Neoplasms,  ligation  in  con- 
tinuity in,  349 
of  lung,  sputum  in,  274 
Nephralgia  and  allied  con- 
ditions, urine  in,  272 


Nephritis,  acute,  influence  in 
surgical  prognosis,  268 
chronic,  influence  in  sur- 
gical prognosis,  268 
post-anesthetic,  urine  in, 

•267 
suppurative,  urine  in,  272 
Nerve    anastomosis   in    in- 
tractable facial  paraly- 
sis, 626 
crushing  of  divided  cen- 
tral end,  356 
dental,    inferior,    neurec- 
tomy of,  542 
facial,  neurectomy  of,  545 
paralysis  of , intractable, 
nerve   anastomosis 
in,  626 
trismus       associated 
with,  188 
stretching  of,  545 

Hueter's method,  545 
fifth,  neurectomy  of  sec- 
ond and  third  divisions, 
with  avulsion    of   Gas- 
serian  ganglion,  541 
hypoglossal,    injuries    of, 

625 
laryngeal,     recurrent     in- 
juries of,  625 
paralysis  of,  after  thy- 
roidectomy, 617 
lingual,     neurectomy    of, 

544 
maxillary,  superior,  neu- 
rectomy of,  540 
by  means  of  temporary 
resection     of     malar 
bone,  540 
resection  of,  540 
phrenic,  injuries  of,  625 
pneumogastric,      injuries 

of,  625 
spinal  accessory,  injuries 
of,  625 
neurectomy  of,  638 
stretching,        intraspinal, 

638 
supraorbital,  neurectomy 
of,  544 
Nerves,  breaking  strain,  357 
cervical,  injuries  of,  625 
cicatricial  union,  354 
contusions  of,  114 
diseases  of,  114 
division  of,  116 
inflammation      of,      118. 

See  also  Neuritis. 
infraorbital,     neurectomy 

of,  540 
injuries  of,  114 

anesthesia  after,  117 
intercostal,   neuralgia  of, 

673 
myomas  of,  removal,  356 
of  facial  region,  540 
operations  on,  354 


12 


INDEX 


Nerves,  pressure  on,  during 
sleep,  116 
strangulation  of,  355 
stretching  of,  357 
suture  of,  354 
primary,  118 
secondary,  118,354 
transplantation  of,  355 
tumors     of,     extirpation, 
356 
Neuralgia,  facial,  intraneu- 
ral   injections  of  osmic 
acid  in,  544 
of  breast,  657 
of  intercostal  nerves,  673 
Neurectomy,  355 

Abbe's  intracranial,  541 
and   stretching    of     facial 
nerve,  545 
Hueter's      method, 
545 
of  inferior   dental   nerve, 
542 
intrabuccal    meth- 
ods, 543 
method  by  tempor- 
ary resection    of 
lower  jaw,  543 
method  by  tempo- 
rary resection  of 
malar  bone,  543 
method     without 
bony     resection, 
544 
methods      without 
chiseling      bone, 
543 
of  infraorbital  nerves,  540 
of  lingual  nerve,  544 
of  second  and  third  divi- 
sions of  fifth  nerve  with 
aA^ulsion    of    Gasserian 
ganglion,  541 
of  spinal  accessory  nerve, 

638 
of       superior      maxillary 
nerve,  540 
by  means  of  tem- 
porary resection 
of    malar    bone, 
540 
of  supraorbital  nerve,  544 
Neuritis,  118 
acute,  119,  120 
ascending,  119,  356 
chronic,  119 
spreading,  119 
traumatic,  119 
Neurofibroma,  220 

removal,  356 
Neurofibromatosis,  226 
Neurogenous      contracture, 

159 
Neurolipoma,  217 
Neuroma,  226 
multiple,  226 
plexiform,  226 


Neuroplastic  operations,  354 
Neurotomy,  355 
Nevi,   capillary,   of  tongue, 
555 
cavernous,  227 
lymphatic,  228 
of  facial  region,  477 
pigmentosi,  removal,  333 
simple,  227 

venous,  of  tongue,  556 
Newborn,  mastitis  of,  654 

syphilitic  rhinitis  in,  503 
Nicolaier,  bacillus  of,  29 
Nipple,  chancre  of,  204 

Paget's  disease  of,  658 
Nirvanin  anesthesia,  306 
Nitric-magnesium    test    for 

albumin  in  urine,  261 
Nitrogen,  injection  of,  into 

pleural  sac,  683 
Nitrous      oxid      anesthesia, 

289,  302 
Noma,  475 

Nose,    abscess    of,    subperi- 
chondrial,  590 
bony  defects,  Dawbarn's 

operation  for,  512 
coA'ering  of,  inflammation 
of,  500 
tumors  of,  500,  502 
destruction  of,  502 
enchondroma  of,  506 
erysipelas  of,  500 
foreign  bodies  in,  499 
granulating    proliferative 

processes,  509 
lupus  of,  501 
mucous     membrane,     in- 
flammations of,  502 
tumors  of,  503 
ulceration  of,  503 
osteoma  of,  505 
osteoplastic  resection,  506. 
See  also  Osteoplastic  re- 
section of  nose. 
papilloma  of,  504 
polypi  of,  503 

cocain  anesthesia  in  re- 
moval, 505 
saddle,  operation  for,  510 
soft  parts,  495 
svphilitic     affections     of, 
508 
ulceration  of,  502 
tuberculous  affections  of, 
509 
ulceration  of,  509 
ulceration  of  glanders  in, 
503 
Nutrient  gelatin,  method  of 
making,  20 


Oblique  bandage,  390 

of  head,  404 

of  jaw,  407 
Obstructive  embolus,  106 


Occipital    lobe,   lesions    of, 

469 
Occipitofacial  bandage,  406 
Odontoid    process,   disloca- 
tions of,  645 
fracture  of,  641,  645 
Odontoma,  219 
compound,  220 
follicular,  219 
epithehal,  219 
fibrous,  219 
folHcular,  219 
of  jaw,  532 
radicular,  219 
treatment,  220 
O'Dwyer's     intubation     in- 
struments, 605 
method  of  intubation  of 
larynx,  604 
Oil,  carljolized,  62 

of   turpentin    in    hemor- 
rhage, 343 
Ointment,  boric  acid,  62 

zinc  oxid,  63 
Ointments,  antiseptic,  62 
Oliguria,  260 

Ollier's     method     of     skin- 
grafting,  332 
operation   of  osteoplastic 
resection  of  nose, '507 
Operations,  causes  of  death 
after,  286 
complications  after,  284 
dangers,  common,  281 

special,  283 
general        considerations, 

280 
imperative,  280 
in  general,  280 
midtiple,  281 
of  expediency,  281 
of  necessitv,  280 
of  utiHty,  280 
preparation  of  patient,  49 
of    surgeon    and    assis- 
tants, 50 
unjustifiable,  281 
Operative   technic,   aseptic, 
48 
general  principles,  308 
Oral    cavity,    examination, 

545 
Orchitis,  589 
Ormsby's  inhaler,  294 
Orthoform,  306 

anesthesia,  306 
Osmic  acid,  intraneural  in- 
jections, in  facial  neural- 
gia, 544 
Osseous  ankylosis,  161 

tumors  of  tongue,  555 
Ossifying  goiter,  611 

periostitis,  138 
Osteitis,  rarefying,  145 
Osteoarthritis,  157,  158 
Osteochondritis,    syphilitic, 
204 


INDEX 


713 


Osteoclasis,  137 
Osteoclast,  Kizzoli's,  362 
Osteoma,  21 S 
cancellous,  21S 
compact,  21S 
nasal,  505 

of  frontal  sinuses,  51S 
of  jaw,  532 

syphilitic,       of       cranial 
bones,  453 
Osteomalacia,  144 
Osteomyelitis,  acute,  140 
infectious,    of     cranial 
bones.  452 
of  jaw,  52S 
suppurative,  139 
syphilitic.  142 
Osteoplastic     resection     of 
nose,  506 
Bruns's  method,  507 
Langenbeck's    meth- 
od, 507 
Ollier's  method,  507 
rhinoplasty,  Konig's,  511 
Osteopsathyrosis,  145 

tabetica,  145 
Osteotomy.  162 

for  correction  of  contrac- 
ture and  ankylosis,  374 
Othematoma  of  auricle,  578 
Otitic  cerebral  abscess,  462 
Otitis  externa.  5S1 
interna,  5S2 
media,  5S2 
Otoplasty,  5S3 
Otoscope,  electric  light,  5S0 
Oval  amputation,  379 
Ovarian     cysts,     fluid     ob- 
tained in,  278 
Ozena,  502 


Pachydermatous  cachexia, 

616 
Pachvmeningitis  in  fracture 

of  skull.  443    ' 
Paset's    disease    of    nipple, 

658 
Pain  in  inflammation,  8 
Palate,  hard.  561 

cleft  of.  562  » 

functional      disturb- 
ances  in   newborn  , 
from,  562  , 

uranoplasty  in,  564 
necrosis  of,  562  [ 

suppurative    periostitis  i 

of,  562 
syphilis  of,  562 
hook,  French's,  499 
sarcoma  of,  533 
soft,  558 
cleft  of,  559 

staphylorrhaphy    in, 
560 
fissures  of.  559 
congenital,  559 


Palate,  soft,   foreign  bodies  ' 
in,  558 
inflammation  of.  558 
svphilitic  ulceration  of, 
■  559 

velum  of,  558 
wounds  of.  558 
Palmar  application  of  figure- 
of-S    bandage   of  hand 
and  wrist,  418 
demi  -  gauntlet   bandage. 
420 
Palpation    in    diagnosis    of 
foreign  bodies,  384 
of  inflammation,  33 
Paper-wool.  63 
Papillary  dermatitis,  malig- 
nant, of  breast,  658 
synovitis,  152 
tendovaginitis,  163 
Papillomar  229 
nasal,  504 

of  larvnx     and     trachea. 
606 
I       of  tongue,  557 
I       viUous^  229 
I  intracystic,  230 

Papular  syphilide.  197 
Paracentesis     of     pericard- 
iiun,  685 
I  Paradenitis,  110 

interstitial,  of  breast,  655 
I  of  lateral  cer-\-ical  region, 
!  62S 

Paralvsis,  crutch,  115 
diphtheritic,  603 
facial,   intractable,   nerve 
anastomosis  in,  626 
trismus  associated  with, 
188 
of      recurrent     laryngeal 
nerve    after    thyroidec- 
tomy, 617 
of  vocal  cords  after  laryn- 
geal diphtheria,  603 
Saturday-night.  115 
Paralytic  wryneck,  650 
Paramastitis,  656 
Parasites,  IS 

facultative,  IS 
Parasynovitis,       treatment, 

157 
Parenchyma,  renal,  pj-ehtis 
with  hyperemia  of,  urine 
in,  269 
Parenchymatous     h  e  m  o  r  - 

rhage.  arrest  of,  342 
Parietal     lobes     of     brain, 

lesions  of,  468 
Park's  modification  of  Gus- 
senbauer's      artificial 
larynx,  609 
Parotid  duct,  fistula  of.  587 
foreign  bodies  in,  588 
injuries  of,  587 
gland,  adenoma  of.  591 
adenosarcoma  of,  591 


Parotid     gland,   chondroma 
of,  .590 
extirpation  of.  591 
injuries  of,  586 
sarcoma  of,  590 
telangiectases  of,  591 
tumors  of,  590 
Pasteur's    prophylactic    in- 
oculation in  hydrophobia, 
192 
Pathogenic  bacteria,   speci- 
fic, 29 
Pathologic  examinations  in 
diagnosis   and    progno- 
sis. 244 
histology  in  diagnosis  and 
prognosis.  245 
Peat.  63" 

moss,  63 
Peh'is.  renal,  acute  catarrh 

of.  urine  in.  269 
Periarticular  inflammations, 

1.5S 
Pericardiotomy.  685 

followed  by  drainage,  in 
pyopericardiimi,  685 
Pericardium.  684 
dropsy  of,  685 
paracentesis  of,  685 
wounds  of.  684 
Perichondritis,  granular,   of 

ribs.  673 
Periosteal  elevator,  367 
lipomas.  217 
sarcomas.  145 
Periostitis.  138 
fibrous.  138 
ossifying.  138 
serous.  138 
suppurative.  138 
of  hard  palate,  562 
of  jaw.  527 
of  ribs,  673 
s}-philitic,  142 
Peripheral  Hgation  in  aneu- 
rism, 346 
Peripleuritis,     suppurative, 

673 
Peritonsillitis,  566 
Pernio,  75 

treatment,  76 
Peruvian  balsam  gauze,  63 
Pes  paralyticus,  159 
Petit's     screw     tourniquet, 

336 
Petri  dishes,  22 
Petrissage,  64 
Pharyngeal  cavity,  care  of, 

before  operation,  49 
Pharyngectomy,      external, 
in  malignant  tumors,  569 
Pharyngitis,  572 
acute.  572 

catarrhal,  subacute,  572 
gangrenous.  573 
phlegmonous,  573 
acute  infectious,  573 


714 


INDEX 


Pharyngitis  sicca,  502 

ulcerative,  573 
Pharynx,  566 

erysipelas  of,  573 
foreign  bodies  in,  570 
inflammation      of,      572. 
See  also  Pharyngitis. 
Phlebitis,  101 
Phlegmon,  nonsyphilitic,  of 

tongue,  548 
Phlegmonous  erysipelas,  177 
inflammation,  11 

subpectoral,  654 
pharyngitis,  573 

acute  infectious,  573 
tonsillitis,  566 
Phosphorus  necrosis  of  jaws, 

528 
Phrenic   nerve,   injuries   of, 

625 
Piano-wire  ecraseur,  315 
Pick's    solution,    No.  1,  244 

No.  2,  245 
Pilcher's  retractors,  600 
Pirogoff's  edema,  181 
Plaster,  adhesive,  402 
coaptation  by,  326 
resin,  402 
rubber,  402 
surgeon's,  402 
uses,  402 
Plaster  -  of  -  Paris  bandage, 
dangers,  396 
method  of  preparation, 

395 
removable,  395 
removal,  .396 
Plastic  operations  on  chest, 
679.     See  also  Thor- 
acoplasty. 
on  skin,  327 

after-treatment,  333 
autoepidermic,  331 
basket-strapping  for, 

333 
flap    formation   with 

torsion,  329 
general  methods,  328 
lateral    displacement 

of  tissues,  328 
Olher  method,  332 
Reverdin's     method, 

331 
Thiersch's      method, 
331 
Plate  method  of  isolation, 

22 
Pleural     sac,     injection     of 

nitrogen  into,  683 
Pleurectomy,  total,  680 
Pleuritic  effusions,  675 
encysted,  675 
incision  in,  677 
resection  of  rib  in,  678 
simple  puncture  and  as- 
piration in,  676 
thoracotomy  in,  677 


Pleuritis,  simple,  with  effu- 
sion, 675 

Pleurotomy  with  detach- 
ment of  visceral  layer  of 
diseased  pleura,  679 

Plexiform  angiomas,  228 
neuroma,  226 

Plexus,  brachial,  stretching 
of,  637 
cervical,  branches  of,  di- 
vision of,  625 
stretching  of,  638 

Plumbism  in  gunshot  in- 
juries, 176 

Pneumatocele,  cranial,  454 

Pneumectom}^  683 

Pneumogastric  nerve,  in- 
juries of,  625 

Pneumonia  after  ether  an- 
esthesia, 296 
post-operative,  285 
septic,    following    wounds 
of  the  thorax,  652 
post-operative,  285 

Pneumopyopericardium,685 

Pneumothorax,  624 

Pneumotomy,  indications 
for,  682 

Podagra,  154 

Pointing  of  abscess,  12 

Poisoned  wound,  2 

Poisoning,      carbolic      acid, 
treatment  of,  60 
iodoform,  treatment  of,  61 
lead,  of  gums,  528 

Polyarthritic  synovitis,  153 

Polycystic  degeneration  of 
kidney,  urine  in,  270 

Polymazia,  657 

Polypanarthritis,  hyperplas- 
tic, 155 

Polypi,  aural,  582 

fibrous,  of  tongue,  555 
nasal,  503 

cocain  anesthesia  in  re- 
moval, 505 
of  esophagus,  621 
of  frontal  sinuses,  518 
snare,  Wilde's  aural,  582 

Polyuria,  260 

Pons,  tumors  of,  470 

Port  wine  stains,  227 

Post  -  anesthetic  nephritis, 
urine  in,  267 

Postmortem  thrombi,  103 

Post  -  operative     complica- 
tions, 284 
Postrectal  dermoids,  237 

Potato  as  culture  medium, 
21 

Pott's  disease,  646 
fracture,  149 

Powder  grains  in  face,  474 

Precedent  anesthesia,  301 

Precocious  gummas,  198 
syphilis,  malignant,  197 

Pregnancy,  sarcoma  of,  370 


Pressure  bandages,  392 

blood-,  259 

on    nerves    during    sleep, 
116 

ulceration  from,  69 
Probang,  umbrella,  620 
Probe  in  inflammation,  36 

telephone,  385 
Probes      in      diagnosis      of 

foreign  bodies,  384 
Probing  for  bullet    in  cran- 
ial cavity,  451 
Productive  inflammation,  8 
Projecting  ears,  583 
Propulsion     diverticula     of 

esophagus,  621 
Prostatic  adenomas,  232 
Provisional  callus,  130 
Psammoma,  230 
Pseudarthrosis,  131 

implantation  of  ivory  pegs 
in,  368 
Pseudocysts,  239 
Pseudoleukemia,  113 

blood  examination  in,  259 
Psoriasis,  simple,  of  tongue, 
547 

syphilitic,  of  tongue,  547 
Ptomains,  19 

Pulmonary       decortication, 
679 

edema   after   ether   anes- 
thesia, 296 
Pulse     and    respiration     in 

fever,  46 
Puncture  and  aspiration  in 
pleuritic  effusions,  676 

exploratory,  in  diagnosis 
of  inflammation,  36 

lumbar,  278 

of  capsule  in  hemarthro- 
sis,  370 
Punctured  wounds,  1 
of  arteries,  86 
of  esophagus,  618 
of  tongue,  546 
Puncturing,  319 
Purulent  edema,  acute,  181 

inflammation,  8 
Pus  in  urine,  267 

laudable,  3 

organisms,  26 
Putrefaction,  process  of,  14 
Putrid  exudates,  278 
Pyelitis  with  hyperemia  of 

renal  parenchyma,   urine 

in,  269 
Pyelonephritis,  urine  in,  270 
Pyemia,  101,  184 

actinomycotic,  212 

cryptogenic,  184 

metastasis  in,  184 

multiple,  of  gums,  527 

spontaneous,  184 
Pyemic  abscess  of  gums,  527 
Pyonephrosis,  urine  in,  270 
Pyopericardium,  685 


INDEX 


715 


Pyothorax,  624,  672 
Pyuria.  267 


Racemose      aneurism      of 

scalp,  433 
Rachitic  rosary,  144 
Rachitis,  144 

Rack  -  and  -  pinion   mouth- 
gag,  564 
Radicular  odontomas,  219 
Ranula,  591 
acute,  592 
Rarefying  osteitis,  145 
Raspatories  for  uranoplasty, 

564 
Rectal  dermoids,  237 
Rectum,  care  of,  before  ope- 
ration, 49 
dermoids  of,  237 
Recurrent  bandage,  392 
of  foot,  425 
of  head,  404 
of  stump,  393 
laryngeal   nerye,    injuries 
of,  625 
paralysis     of,      after 
thyroidectomy, 61 7 
syphilides,  198 
Recurring  hemorrhage  after 

operations,  284 
Red     corpuscles,     counting, 

249 
Redness  of  inflammation,  7 
Redressing   wound,    indica- 
tions for,  57 
Reflector,    Collin's    electric 

light,  597 
Refracture,  137 
Regeneration  of  callus,  130 
Regenerative  inflammation, 

8_ 
Regional  surgery,  429 
Reinfection,  syphilitic,  203 
Removable     layer     suture, 

323,  324,  325 
Renal.     See  Kidney. 
Resection,  diaphysial,  367 
enucleation,  of  goiter,  616 
in  fractures,  368 
of  alveolar  processes,  534 
of  both  superior  maxillas 
in  two  sittings,  539 
upper   maxillas,    simul- 
taneous, 539 
of  callus,  137 
of  entire  lower  jaw,  537 
of  esophagus,  624 
of  fractures,  368 
of  goiter,  615 
of  half  lower  jaw,  535 
of  joints,  371 

after-treatment,  374 
for  tuberculous  myelitis, 
374 
synovitis,  374 
general  technic,  373 


Resection  of  joints,  immedi- 
ate, 372 
intermediate,  372 
partial,  372 
primary,  372 
secondary,  372 
subcapsular,  373 
subperiosteal,  373 
of  lower  jaw,  534 
of  lung,  683 

of  rib    in    pleuritic    effu- 
sions, 678 
of  spine     in     fracture    of 
cervical  vertebrae,  642 
of  sternum       for       chon- 
droma, 675 
of     superior       maxillary 

nerve,  540 
of  temporo  -  maxillary  ar- 
ticulation, 537 
of  upper  jaw,  537 
osteoplastic,  of  nose,  506. 
See  also  Osteoplastic  re- 
section of  nose. 
Resin  plaster,  402 
Resorptive  fever,  47 
Respiration    and    pulse    in 
fever,  46 
artificial,     in     dangerous 
anesthesia,  300 
Laborde's  method, 

300 
Sylvester's     meth- 
od, 300 
Cheyne-Stokes,     in    frac- 
ture of  skull,  440 
Retching,    excessive,    after 

operations,  284 
Retention  cysts,  239 

of  urine  after  operations, 
284 
Reticular  lymphangitis,  108 
Retractor  bandages,  401 

cheek,  560 
Retractors,  Pilcher's,  600 
Retropharyngeal       abscess, 

646 
Reverdin's  method  of  skin- 
grafting,  331 
Rhabdomyomas  of  tongue, 

555 
Rhabdomyosarcoma,  222 
Rheumatism,  acute,  153 
Rheumatoid  arthritis,  152 
Rhinitis,    chronic    atrophic, 
502 
chronic  hypertrophic,  502 
syphilitic,     in     newborn, 
503 
Rhinophyma,  501 
Rhinoplasty,  509 

Busch's  method,  511 
complete,  510,  513 
Konig's  method,  513 
Schimmelbusch's  meth- 
od, 514 
Konig's,  511 


Rhinoplasty,    partial,    510, 

513 
Rhinoscleroma,  501 
Rhinoscopy,  497 

anterior,  498 

posterior,  498 
Rib,  cervical,  630,  649 

exostosis  of,  649 

resection  of,   in  pleuritic 
effusions,  678 
Ribs,  angiosarcoma  of,  674 

carcinoma  of,  674 

caries  of,  672 

chondroma  of,  673 

fractures  of,  670 

granular  myehtis  of,  672 
perichondritis  of,  673 

sarcoma  of,  674 

separation  of,  from  ster- 
num, 681 

suppurative  periostitis  of, 
673 

syphilitic  disease  of,  673 

tumors  of,  673 

typhoid  infection  of,  673 
Richter's     needle  -  holder, 

322,  323 
Riga's  disease,  557 
Rizzoli's  osteoclast,  362 
Roberts's  method  of  treat- 
ing  fractures   of   lower 
jaw,  523 

trephine,  314 
Rodent  ulcer  of  face,  478 
Roe's    modification  of  Mac- 
kenzie's      esophagotome, 

623 
Rolando,  fissure  of,  localiza- 
tion, 467 
Chiene's    device    for, 
467 
Roller  bandages,   varieties, 

390 
Rongeur  forceps,  314,  317 
Rontgen  ray  in  diagnosis  of 

foreign  bodies,  384 
Rose's  dependent  head  posi- 
tion, 534 
Round-celled  sarcomas,  222 
Round-cells,  formative,  5 
Rubber  bandage,  393 

plaster,  402 

tourniquet,  393 
Rudisch    quantitative    test 

for  glucosuria,  262 
Rupture  aneurisms,  95 

of  sternomastoid   muscle, 
624 

of  tendons,  122 

of  tracheal  mucous  mem- 
brane, 595 
of  varicose  vein,  101 


Sacciform  aneurism,  94 
Saddle  nose,  operation  for, 
510 


716 


INDEX 


Salicylic  acid,  61 

cream,  62 
Saline     infusion,     intraven- 
ous, 351 
Salivary  calculus,  588 
glands,  586 

inflammation  of,  589 
Salivolithiasis,  588 
Sandelin's  cheiloplasty,  483 
Saprophytes,  18 
Sarcinae,  18 
Sarcoma,  221 

blood  examination  in,  258 
central,  of  bone,  145 
character,  general,  224 
degenerative  changes,  225 
dissemination  of,  225 
distribution,  224 
giant-celled,  222 
infiltrating  properties, 225 
intraocular,  477 
melanotic,  removal,  335 
metastasis  of,  225 
of  alveolar  process,  533 
of  antrum   of   Highmore, 

530 
of  bone,  145 

operation  for,  370 
central,  145 
of  breast,  658 

cystic,  658 

phjdloid,  658 
of  cervical  vertebral  col- 
umn, 649 
of  cranial  bones,  454 
of  eye,  477 

of  frontal  sinuses,  519 
of  glands  of  neck,  632 
of    involuntary    muscle  - 

fiber,  122 
of  jaw,  532 

of  joints,  treatment,  376 
of  larynx,  606 
of  lung,  683 
of    mucous     membranes, 

224 
of  muscles  of  neck,  630 
of  nasopharynx,  576 
of  neck,  operation  in,  639 
of  orbit,  454 
of  palate,  533 
of  parotid  gland,  590 
of  pregnancy,  370 
of  ribs,  674 
of  scalp,  434 
of  sternum,  675 
of     submaxillary     gland, 

591 
of    synovial     membrane, 

treatment,  376 
of  tendons,  removal,  360 
of  thyroid  gland,  617 
of  tonsils,  569 
of  vagina,  224 
of  voluntary  muscles,  121 
periosteal,  145 
round-celled,  222 


Sarcoma,  secondary  changes, 
225 

spindle-celled,  222 

tendency  to  penetrate  be- 
tween surrounding 
structures,  225 

treatment,  226 
Saturday  -  night    paralysis, 

115 
Saw,  Adams's,  363 

broad,  311,  313,  361 

chain,  312,  361,  362 

frame,  311,  313,  361 

GigU  wire,  312,  361,  362 

metacarpal,  362 
Sawdust,  63 
Sawing,  division  of  bone  by, 

361 
Saws,  311 

Scabbard  trachea,  612 
Scalds  of  tongue,  546 
Scale,   Tallqvist's   hemoglo- 
bin, 249 
Scalp,  aneurism  of,  433 
cirsoid,  433 
racemose,  433 

avulsion  of,  430 

cirsoid  aneurism  of,  433 

contusions  of,  simple,  429 

dermoid  cysts  of,  433 

dermoids  of,  235 

fibroma  of,  434 

hematoma  of,  429 

hpoma  of,  434 

loosening  of,  without 
avulsion,  431 

racemose  aneurism  of,  433 

sarcoma  of,  434 

surgery  of,  429 

tumors  of,  433 

varices  of,  434 

venous  cysts  of,  434 

wounds  of,  429 

inflammation  after,  431 
Scalpel  rack  and  case,  50 
Scalpels,  308 
Scar  tissue,  abscess  in,  68 
Schede's  operation  of  thor- 
acoplasty, 679 
Schimmelbusch's     complete 
rhinoplasty,  514 

meloplastic  operation,  494 

sterilizer,  50 
Schmidt's  fibrin  ferment,  47 
Scirrhus  of  breast,  659 
Scissors,  Asch's,  496 

bandage,  390 

curved  on  the  flat,  310 
Scoliosis,  646 

compensatory,  651 
Scrofulous    edema    of    lips, 

477 
Scrotum,  dermoids  of,  236 
Scurvy  and  allied  conditions, 

blood  examination  in,  258 
Sebaceous  adenomas,  231 

cysts,  231 


Sebaceous  horns,  230 
Sections,      embedded,      in- 
structions  for  making, 
246 
frozen,     instructions     for 
making,  245 
Senile  gangrene,  93,  106 
Septic  arthritis,  acute,  152 
inflammation,  post-opera- 
tive, 285 
lymphadenitis    of    lateral 

cervical  region,  628 
pneumonia,       following 
wounds  of   the  thorax, 
652 
pneumonia,   post  -  opera- 
tive, 285 
synovitis,  acute,  156,  157 
wounds,  2 
Septicemia,  182 
Septicopyemia,  182,  184 
Septum,     nasal,    deviations 

of,  496 
Sequestra,  140 
Sequestration  dermoids,  235 
Sequestrotomy,  369 
Sequestrum  forceps,  369 
Serofibrinous  inflammation, 

8,  9  • 

Serohemorrhagic  inflamma- 
tion, 8,  9 
Serous  inflammation,  8 

periostitis,  138 
Serpentine  bandage  of  foot, 
426 
of  great  toe,  428 
Serpiginous  ulcer,  83 
Serum,    blood-,    human,    as 

culture-medium,  21 
Seton  gunshot  wound,  652 
Sheets,  disinfection  of,  53 
Shock,  282 

Shoulder,    ascending    spica 
bandage  of,  414 
descending  spica  bandage 
of,  415 
Sialadenitis,  589 
Sialodochitis,  590 
Silk,  sterilization  of,  55 
Simon's  operation  for  single 

harelip,  488 
Sinus,  12 

curet,  Delatovir's,  58 
frontal,  inflammation  of, 
515.     See  also  Frontal 
sinusitis. 
syringe,  59 

thrombosis,  infectious,464 
Sinuses,  frontal,  514.       See 
also  Frontal  sinuses. 
of    dura    mater,    hemor- 
rhages from,  in  fracture 
of  skull,  441 
Sinusitis,  frontal,  515.      See 

also  Frontal  sinusitis. 
Skin,  abrasions  of,  67 
actinomycosis  of,  212 


INDEX 


717 


Skin,  contvisions  of,  GG 
epidermal  layer  of,  forma- 
tion, 68 
gunnna  of,  82 
inflammation  of,  granular, 
79 
suppurative,  67 
injuries  of,  66 
losses  of  substance  in,  68 
of  face,  powder  grains  in, 

474 
of  neck,  tumors  of,  630 
operations  on,  327 
plastic  operations  on,  327. 
See  also  Plastic  Opera- 
tions on  Skin. 
suppurative  inflammation 

of,  67 
syphilis  of,  82 
traumatism  of,  66 
tuberculosis  of,  79 
tumors  of,  removal,  333 
ulceration  of,  69 
wounds  of,  noncommuni- 
cating,  in  fracture,  126 
Skin-grafting,     327.         See 
also  Plastic  operations  on 
skin. 
SJvin-stretching  hooks,   Mc- 

Burney's,  332 
Skull,  bones  of,  434.        See 
also  Cranial  bones. 
diseases    of,     abscess     of 
brain  developing  from, 
463 
fracture  of,  434 
base,  436 
cerebral  complications, 

438 
Cheyne-Stokes  respira- 
tion in,  440 
compound,  443 

pachymeningitis     in, 
443 
compression     of    brain 

in,  439 
concussion  of  brain  in, 

441  _ 
contusion   of  brain   in, 

442,  455 
laceration   of  brain  in, 

442 
trephining,  447 
hemorrhages  from    sin- 
uses of  dura  mater  in, 
441 
Sling,  397 

arm  and  hand,  417 
bandage,  for  breast,   414 
Smear  preparation,  25 
Smegma  bacillus,  31 
Smoker's  patch,  547 
Snare,  Jarvis's,  504 

Wilde's,  582 
Snowball  crackling,  146 
Soft  palate,  558.     See  also 
Palate,  soft. 


Sore,   primary,   of  acquired 
syphilis,  197 
throat,  hospital,  573 
Spanish  windlass,  337 
Spasm,  mimic,  545 
Spasmodic  wryneck,  650 
Spastic  torticollis,  650 
Speculum,  Brophy's  mouth, 
559 
ear,  580 
nasal,  498 
Spica  bandage,  392 

ascending       of       both 
groins,  423 
of  shoulder,  414 
single,  of  groin,  421 
descending,      of      both 
groins,  424 
of  shoulder,  415 
single,  of  groin,  422 
of  foot,  425 
of  great  toe,  427 
of  thumb,  420 
Spinal  accessory  nerve,  in- 
juries of,  625 
neurectomy  of,  638 
anesthesia,  306 
cord,  gliomas  of,  227 
Spindle-celled  sarcoma,  222 
Spine,  resection  of,  in  frac- 
ture of  cervical  vertebrae, 
642 
Spiral  bandage,  390 
of  chest,  411 
of  finger,  419 
of  foot,  424 
reversed,  391 
of  finger,  419 
of    lower   extremity, 

426 
of    upper  extremity, 
418 
fractures,  123 
Spirillum,  18 

Splint,  interdental,  in  frac- 
tures of  lower  jaw,  521 
Matas's,    in    fractures    of 

lower  jaw,  523 
Roberts's,  in  fractures  of 
lower  jaw,  523 
SpUntered  fracture,  125 
Split  tongue,  549 
Splitting  cheek  in  cancer  of 

tongue,  553 
Spondyhtis   in   cervical   re- 
gion, 646 
Spoon,  sharp,  315 

diAasion  of  bone  by,  364 
Sporulation,  19 
Spreading  neuritis,  119 
Sputum,  examination  of,  273 
in  abscess  of  lung,  274 
in  empyema  rupturing  in- 
to lung,  274 
in  hemoptysis  due  to  per- 
forating aneurism,  274 
in  neoplasm  of  lung,  274 


Squamous-celled  carcinoma, 

234.  See  also  Epithelioma. 

Stab  wounds  of  larynx  and 

trachea,  595 
Stagnation  thrombi,  102 
Stain,    alkaline    methylene- 
blue,  for  bacteria,  25 
Gram's,  25 
port  wine,  227 
Ziehl-Neelsen,   for   tuber- 
cle bacilli,  25 
Staining  methods,  24 
Staphylococcus,  18 
epidermidis  albus,  26 
pyogenes  albus,  26 
aureus,  26 
citreus,  26 
Staphylorrhaphy,  560 
dividing  muscles,  561 
introducing  sutures,  561 
paring  margins,  560 
Stasis,  venous,  103 

gangrene      after,     104, 
105 
Stay  knot,  340 
Steatoma  of  mastoid,  586 
Stenosis,  laryngeal.    See  also 

Stricture. 
Stenson's  duct,  587.         See 

also  Parotid  duct. 
Sterilization,  fractional,  20 
of  catgut,  53 

apparatus  for,  54 
iodin  method,  55 
of  cocain  solutions,  305 
of  ligature  material,  53 
of  silk,  55 

of  suture  material,  53 
SteriUzer,  Arnold,  53 
hospital,  51 
hot-air,  25 
Schimmelbusch's,  50 
Sternomastoid  muscle,  rup- 
ture of,  624 
syphilitic    gummas    of, 
630 
Sternum,  674 

caries  of,  syphilitic,  674 

tuberculous,  674 
chondroma*  of ,  675 
fissure  of,  congenital,  675 
fracture  of,  674 
resection    of,     for    chon- 
droma, 675 
sarcoma  of,  675 
separation   of    ribs   from, 

681 
trephining,  674 
Stevenson's  instrument  for 

electrolysis,  334 
Stitch  abscesses,  57 
Stockinet,  64 

Stomach,      carcinoma      of, 
blood   examination   in, 
258 
contents,  examination  of, 
274 


718 


INDEX 


Stomach  contents,  free  acids 
and   acid    salts  in, 
test  for,  275 
hydrochloric  acid  in, 
"275 
lactic  acid  in,  275 
total  acidity  due  to  or- 
ganic acids  and 
acid    salts,    test 
for,  276 
test  for,  275 
free  hydrochloric  acid 

in,  test  for,  276 
hydrochloric  acid  in, 
test  for,  276 
dilatation  of,  acute  post- 
operative, 284 
lavage  of,  618 
tube,  618 

ulcer  of,  blood  examina- 
tion in,  258 
Stomatoplastic    operations, 
493 
for    ectropion    of    lips, 

494 
for  macrostoma,  493 
for  microstoma,  493 
Strain,    breaking,    of    prin- 
cipal nerves,  357 
Strangulation  of  nerve,  355 
Strapping,  basket,  in  ulcers, 

71 
Strauss  graduated  tube  for 
lactic  acid  determination, 
275 
Streptococcal    infection    of 

breast,  656 
Streptococcus,  18 

pyogenes,  27 
Stretching,  intraspinal 

nerve-,  638 
nerve-,  357 

of  brachial  plexus,  637 
of  cervical  plexus,  638 
Stricture,  carcinomatous,  of 
esophagus,     treatment, 
623 
cicatricial,   of   esophagus, 

618,  621 
frorri  tumors  or  cicatricial 
bands,         tracheotomy 
tube  in,  604 
of  esophagus,  621 

Abbe's  method  of  treat- 
ing, 623 
Struma,  610 
Strumitis,  611 
Stump,    recurrent   bandage 

of,  393 
Sty,  475 

Styptics  in  hemorrhage,  343 
Subcapsular     resection     of 

joints.  373 
Subclavian    artery,    hemor- 
rhage from,  arrest  of, 
626 
hgation  of,  636 


Subcutaneous       connective 
tissue,  granular  in- 
flammation of,  79 
gumma  of,  82 
injuries  of,  66 
suppurative     inflam- 
mation of,  67 
hemorrhage,  88 
infusion,  352 

injuries    of    larynx    and 
trachea,  594 
of    smaller    blood-ves- 
sels, 87 
lipoma,  216 
lymphorrhagia,  107 
painful  tubercle,  226 
tenotomy,  122,  360 
traumatism     of     kidney, 
urine  in,  272 
Subluxation,  148 
Submaxillary  duct,   foreign 
bodies  in,  588 
gland,  adenoma  of,  591 
adenosarcoma  of,  591 
chondroma  of,  590 
extirpation  of,  591 
sarcoma  of,  591 
tumors  of,  590 
Submucous  lipoma,  216 
Subpectoral  abscess,  654 
phlegmonous     inflamma- 
tion, 654 
Subperichondrial  abscess  of 

nose,  509 
Subperiosteal      abscess      of 
gums,  527 
cyst    of   alveolar  process, 

532 
fracture,  125 
resection  of  joints,  373 
Subphrenic  abscess,  676 
Subserous  lipoma,  216 
Subsynovial  lipoma,  216 
Subtendinous  bursae,  240 
iSubungual  exostosis,  219 
Sucking  cushion,  217 
Suff'ocation    after    removal 
of      tracheotomy      tube, 
603 
Sugar  in  urine,   262 
Suicidal  hanging,  645 
Suicide    wounds    of    larynx 

and  trachea,  595 
Sulfuric  ether  as  anesthetic, 

289 
Superfluous  callus,  131 
Supernumerary         breasts, 

congenital,  657 
Suppression   of   urine   after 

operations,  284 
Suppuration,  non-bacterial, 
32 
of  demarcation,  75 
of  external  auditory  mea- 
tus, 581 
Supraorbital  nerve,  neurec- 
tomy of,  544 


Suprathyroid   tracheotomy, 
^  602 
Surgeon      and      assistants, 

preparation,  50 
Surgeon's  adhesive  plaster, 

402 
Surgical  bacteriology,  17 
epilepsy,  471 
fever,  39 

and   augmented   meta- 
morphosis, relations, 
43 
respiration    and    pulse 
in,  46 
infections,  chronic,  194 
Suture     after     amputation, 
380 
bone,  365 
buried,  323 
chain-stitch,  323 
continuous,  323 
interrupted,  321 
intracuticular,  323 
layer,  323 

material,  sterilization,  53 
of  arteries,  341 
of' muscles,  357 
of  nerves,  354 

secondary,  354 
of  tendons,  358 
of  veins,  344 
primary,    in    division    of 

nerves,  118 
removable  layer,  323,  324, 

325 
removal  of,  time  for,  58 
secondary,  in  division  of 
nerves,  118 
Suturing,    deep,    in   hemor- 
rhage, 342 
protection  of  line  of,  321 
Sweat-glands,   adenoma  of, 

477 
Swelling  of  inflammation,  7 
Sylvester's  method  of  arti- 
ficial respiration  in  dan- 
gerous anesthesia,  300 
Sympathectomy,      cervical, 

640 
Syncope  in  chloroform  an- 
esthesia, 298 
Synovial  cysts,  239 

membrane,  sarcoma,  376 
Synovitis,  151 
acute,  151 
septic,  156 
serous,  156 
chronic,  151 

serous,  151 
etiology,  153 
granulating,  151 
hyperplastic,  151,  155 

papillary,  155 
hyperplastica    granulosa, 

141 
metastatic      suppurative, 
155 


INDEX 


719 


Synovitis  of  sheaths  of  ten- 
dons, 163 
pannosa,  155 
papillary,  152 
polyarthritic,  153 
septic,  157 
serous,  154 
suppurative,  154 
tuberculous,  151, 153,  155, 
157 
resection  of  joints  for, 
374 
Sj'phihde,  macular,  197 
papular,  197 
recurrent,  198 
Syphilis,  194 
acquired,  194 

initial  lesion  of,  197 
mucous      patches      of, 

197 
primary  incubation  pe- 
riod, 195 
sore,  197 
stage,  197 
secondary      incubation 
period,  195 
stage,  197 
tertiary  stage,  198 
benign,  195 
hereditary,  203 
initial  lesion,  82 
maUgnant,  196 

precocious,  197 
mediate  infection,  194 
of  hard  palate,  562 
of  skin,  82 

secondary  lymphatic  ade- 
nopathy in,  195 
treatment,  199 
general,  199 
hygienic,  200 
specific,  201 
Syphilitic  affections  of  bone, 
142 
of  nose,  508 
alopecia,  198 
bubo,  197 
cachexia,  196,  199 
caries    of    cranial    bones, 
453 
of  sternum,  674 
craniotabes,  204 
disease  of  ribs,  673 
fever,  195 
gummas  of  sternomastoid, 

630 
laryngitis,  599 
lymphadenitis,  113 
necrosis  of  cranial  bones, 

453 
osteochondritis,  204 
osteoma  of  cranial  bones, 

453 
osteomyelitis,  142 
periostitis,  142 
psoriasis  of  tongue,  547 
reinfection,  203 


Syphilitic  renal  hyperplasia 
simulating      malignant 
growth,  urine  in,  270 
rhinitis  in  newborn,  503 
ulceration  of  nose,  502 
of  soft  palate,  559 
of  tonsils,  566 
Syphiloma,  196 
Syringe,  Collin's,  320 
ear,  580 
sinus,  59 


Tabetic  arthritis,  154 
arthropathy,  152 

Tallqvist's  hemoglobin  scale, 
249 

Tampon,  chemise,  in  hemor- 
rhage, 342 

Tamponade  in  hemorrhage, 
342 

Tampons  in  ant.  nares,  ban- 
dage for  supporting,  410 

Tapotement,  64 

T-bandage,  double,  398 
of  chest,  398 
single,  398 

Teeth,  Hutchinson,  204 

Telangiectasis,  227 
of  parotid  gland,  591 

Telephone  probe,  385 

Temperature  of  body,  phy- 
siologic regulation,  39 

Temporo-maxillary  articula- 
tion, resection  of,  537 

Tenaculum  forceps,  double, 
309 

Tendogenous    contractures, 
159 

Tendons,  contractured, 

lengthening,  358 
diseases  of,  122 
fibroma  of,  360 
ganglions  of,  360 
incised  wounds  of,  122 
inflammation  of,  123 
injuries  of,  122 
necrosis  of,  122 
operations  on,  357 
rupture  of,  122 
sarcoma  of,  360 
sheaths    of,    suppurative 
inflammation  in,  359 
synovitis  of,  163 
suture  of,  358 
traumatic  separation,  358 
tumors  of,  operations  for, 
360 

Tendoplastv,  358 
double,  358 
vicarious,  358 

Tendosynovitis.     See   Teno- 
synovitis. 

Tendovaginitis,  163 
papillary,  163 
suppurative,  163 
tuberculous,  163 


Tenosynovitis,      123,      141, 

163 
Tenotomes,  361 
Tenotomy,  360 

subcutaneous,  122,  360 
Teratoma,  238 

auricular,  of  neck,  629 
Test,    bismuth,    for    gluco- 
suria,  262 
for    free    acids    and    acid 
salts     in    gastric     con- 
tents, 275 
for   total   acidity   due   to 
organic   acids   and 
acid   salts   in   gas- 
tric contents,  276 
of    gastric    contents, 
275 
for  total  combined  hydro- 
chloric  acid   in    gastric 
contents,  275 
for  total  free  hydrochloric 
acid  in  gastric  contents, 
276 
for  total  hydrochloric  acid 
in  gastric  contents,  276 
Haines's,    for   glucosuria, 

262 
heat  and  nitric  acid,  for 

albumin  in  urine,  260 
nitric-magnesium,  for  al- 
bumin in  urine,  261 
Rudisch  quantitative,  for 
glucosuria,  262 
Testicle,  dermoids  of,  236 
Tetanus,  44,  187,  530.     See 
also  Lockjaw. 
antitoxin  treatment,  190 
bacillus  of,  29 
cicatricial,  531 

meloplastic       operation 
for,  494 
hydrophobic,  188 
incubation  period,  188 
neonatorum,  188 
treatment,  189 
Tetany      after      thvroidec- 

tomy,  617 
Tetrads,  18 

Thatcher  mosquito,  253,  266 
Thermocautery,  316 
Thermostat,  Dunham's,  23 
Thiersch's  method  of  skin- 
grafting,  331 
Thoma-Zeiss  counting  cham- 
ber, 250 
hemocytometer,  249 
Thoracic   duct,   injuries   of, 
107 
obstruction  of,  107 
region,  actinomvcosis  of, 
211 
Thoracoplasty,  679 

Estliinder's  operation ,  679 
Schede's  operation,  679 
Thoracotomy     in     pleuritic 
effusions,  677 


720 


INDEX 


Thorax,     652.         See     also 

Chest. 
Throat,  hospital  sore,  573 
Thrombo-arteritis,  93 
Thrombophlebitis,  101 
Thrombosis,  102 
dilatation,  102 
infectious  sinus,  464 
intra-arterial,  93 
marasmus,  102 
Thromljus,  extension,  102 
hyaline,  106 
postmortem,  103 
stagnation,  102 
valvular,  102 
white,  104 
Thumb  forceps,  309 

spica  bandage,  420 
Thyrohvoid  bursa,  241 

hydrops  of,  630 
Thyroid,  adenomas  of,   232 
and  cricoid  cartilages,  en- 

chondroma  of,  606 
cartilages,  fracture  of,  594 
gland,  610 

accessory,  mucous  cysts 

of,  611 
adenoma  of,  232,  611 
carcinoma  of,  617 
enlargement    of,     tem- 
porary, 612 
hypertrophy  of,  611 
injuries  of,  610 
malignancy,  617 
sarcoma  of,  617 
Thyroidectomy,      summary 
of  important  points  in, 
616 
tetany  after,  617 
Thyroiditis,  610 
Thyrotomy,  608 
Tic  douloureux,  540 

rotatoire,  650 
Tiemann's     bullet     forceps, 

387 
Tissues,  granulation,  3 
indications     for    uniting, 

321 
mechanism     of     uniting: 
321  ^' 

separate,  injuries  and  dis- 
eases of,  66 
separation  of,  308 

by    means    of    ligature 
and  heat,  315 
of  scissors,  310 
incisions    from    within 

outward,  309 
indications  for,  308 
means  employed  for,  308 
Toe,  great,  serpentine  ban- 
dage of,  428 
spica  bandage  of,  427 
Tongue,  545 
abscess  of,  548 
aneurism  by  anastomosis, 
555 


Tongue,  angioma  of,  555 
arteriovenous      aneurism 

of,  555 
bifid,  549 
burns  of,  546 
cancer  of,  549 

asphyxia     in,     preven- 
tion, 551 

hemorrhage    in,    551 

Kocher's  operation  for, 
554 

median  section  of  lower 
jaw  in,  553 

splitting  cheelv  in,  553 

Whitehead's   operation 
for     extirpation 
of  entire  tongue 
in,  552 
for  extirpation   of 
half    of    tongue 
in,  551 
cirsoid  aneurism  of,  555 
deformities  of,  548 
depressor,    electric    light, 

545 
dermoids  of,  236 
edema  of,   inflammatory, 

546 
erysipelas  of,  548 
fibroma  of,  555 
fibromyoma  of,  548,  555 
gunshot  wounds  of,  546 
ichthyosis  of,  547 
lacerated  wounds  of,  546 
lipoma  of,  555 
lupus  of,  548 
lymphangioma    of,     548, 

556 
nevi  of,  capillary,  555 

venous,  556 
papilloma  of,  557 
phlegmon  of,  nonsyphih- 

tic,  548 
polypi  of,  fibrous,  555 
psoriasis  of,  547 

syphihtic,  547 
punctured  wounds  of,  546 
rhabdomyoma  of,  555 
scalds  of,  546 
spht,  549 
tumors  of,  amyloid,  555 

benign,  555 

cartilaginous,  555 

cavernous,  556 

osseous.  555 
ulceration  of,  547 

tuberculous,  548 
warty  growths  of,  557 
wounds     of,     punctured, 

546 
Tongue-tie,  548 
TonisiUitis,  acute,  566 
diphtheritic,  566 
foHicular,  566 
hypertrophic,  566 

tonsillotomy  in,  567 
phlegmonous,  566 


Tonsillotomes,  568 
Tonsillotomy       in      hyper- 
trophic tonsillitis,  567 
Tonsils,  566 

carcinomatous  ulceration, 

566 
epithelial    carcinoma    of, 

569 
lupous  ulceration,  566 
malignant  tumors  of,  568 
external   pharyngec- 
tomy  in,  569 
sarcoma  of,  569 
syphilitic    ulceration     of, 

566 
tuberculosis  of,  568 
tuberculous  ulceration  of, 

566 
ulcerative    conditions   of, 
566 
Torticolhs,  624,  650 
congenital,  650 
Kocher's    operation    for, 

651 
of  central  origin,  650 
of  muscular  origin,  650 
paralytic,  650 
spasmodic,  650 
spastic,  650 
Tourniquet,  337 
Petit's,  336 
rubber,  393 
Towels,  disinfection  of,  53 
Toxemia    before   and    after 

operations,  268 
Trachea,  594 

diphtheritic        inflamma- 
tion, 598 
fibroma    of,    pediculated, 

606 
foreign  bodies  in,  595 
inflammatory        obstruc- 
tion, 598 
papilloma  of,  606 
pediculated    fibroma    of, 

606 
scabbard,  612 
stab  wounds  of,  595 
subcutaneous  injuries  of, 

594 
suicide  wounds  of,  595 
tumors  of,  606 
ulceration    of,    from    im- 
properly curved  trache- 
otomy tubes,  603 
Tracheal  fistula,  629 

mucous   membrane,   rup- 
ture of,  595 
wall     anterior,    diphther- 
itic ulceration  of,  603 
wound,     granulomas     of, 
603 
Tracheotomy,  599 
after-course,  602 
after-treatment,  602 
anesthetic  in,  599 
choice  of  operation,  600 


IXDKX 


721 


Tracheotomy,  cocain  in,  599 
cricothyroid,  002 
for  foreiijii  hodios,  004 
infrathyroid,  (iOO 
preliminary,  004 
rapid,  000 
suprathvroid,  602 
tube.  001 
Cohen's,  601 
in  stenosis  from  tumors 
or    cicatricial  bands, 
604 
permanent  removal,  604 
suffocation      after     re- 
moving, 603 
Traction  diverticula  of  eso- 
phagus, 621 
Tragus,  accessory,  238 
Transfusion,  351 
Transplantation,  bone,  36S 
of  granulating  flap,  330 
of  nerves,  355 
Transudates,      examination 

of,  277 
Traumatic  abscess  of  brain, 
460 
chronic,  461 
aneurism,  96 
dermoids,  236 
empyema,  672 
erysipelas,  67 
inflammation  of  soft  parts 

of  facial  region,  474 
meningitis,  457 
separation  of  tendons,  35S 
Traumatism  of  skin,  66 
subcutaneous,  of  kidney, 
urine  in,  272 
Trendelenburg  cannula,  534 
Trephine,  312 

aseptic  brace,  447 
Gait's,  313 
Roberts's,  314 
Trephining    in    fracture    of 
skull,  447 
indications  for,  448 
mastoid,  5S4 
sternum,  674 
Triangle  bandage  of  groin, 

401 
Trigonum  linguale,  558 
Trismus      associated      with 

facial  paralysis,  188 
Trocar  and  cannula,  319 

Fitch's.  319 
Tropacocain      hydrochlorid 

anesthesia,  306 
Trunk,  bandages  of,  411 

dermoids  of,  235 
Tubercle,  anatomic,  82 
bacilli,  Ziehl-Xeelsen 

stain  for,  25 
cadaver,  82 
moist.  198 

subcutaneous  painful,  226 
Tuberculosis,  205 
bacillus,  30 
47 


Tuberculosis,  Ijlood  examina- 
tion in,  257 
intestinal,  feces  in,  276 
latent,  207 
of  manuna,  655 
of  skin,  79 
of  tonsils,  568 
pathologic  anatomy,  206 
renal,  urine  in,  271 
treatment,  20S 
Tuberculous     affections     of 

nose,  509 
arthritis,  152 
cachexia,  205 
caries  of  sternum,  674 
endangeitis,  205 
fistula^  207 
granuloma,  207 
gumma,  SI 
hydrops,  151 
inflammation    of    cranial 

bones,  452 
laryngitis,  599 
lymphadenitis.  111 

of   lateral    cervical    re- 
gion, 627 
lymphatic  glands  of  neck, 

extirpation  of,  638 
myehtis,       resection      of 

joints  for,  374 
necrosis,  138 
spondylitis,  646 
synovitis,  151 

resection  of  joints  for, 
374 
tendovaginitis,  163 
ulcer,  81,  207 
ulceration  of  nose,  509 

of  tongue,  548 

of  tonsils,  566 
Tubulocysts,  239 
Tubulodermoids,  236 
Tumors,  214 
benign,  215 

influence     of     environ- 
ment, 215 
cavernous,  treatment,  334 
classification,  214 
connective-tissue,  214 
diagnosis,  241 
epithehal.  229 
erectile,  227 
inflammatory,  590 
malignant,  214 

influence     of     environ- 
ment, 214 
structure.  215 
treatment.  242 
Turbinectomy     in     chronic 

frontal  sinusitis.  517 
Turpentin.  oil  of.  in  hemor- 
rhage. 343 
Typhoid  infection  of  ribs, 673 
laryngitis,  599 

Ulcer,  69 

basket  strapping  in,  71 


miprop- 
tracheo- 


Ulcer,    gastric,     blood    ex- 
amination in,  258 
rodent,  of  face,  478 
serpiginous,  S3 
tuberculous,  81,  207 
varicose,  69 
Ulceration,    carcinomatous, 
of  tonsils,  566 
diphtheritic    of     anterior 

tracheal  wall,  603 
from  pressure,  69 
in   cicatrix,  68 
intestinal,  feces  in,  276 
lupous,  of  tonsils,  566 
of  glanders  in  nose,  503  . 
of  mucous   membrane   of 

nose,  503 
of  skin,  69 
of  tongue,  547 
of  tonsils,  566 
of  trachea   from 
erlv     curved 
tomy  tubes.  603 
syphilitic,  of  nose.  502 
of  soft  palate,  559 
of  tonsils,  566 
tuberculous,  of  nose,  509 
of  tongue.  54S 
of  tonsils,  506 
UlceratiA-e  pharyngitis,  573 
Umbrella  probang,  620 
Unjustifiable        operations, 

2S1 
Uranoplasty,  564 

application     of     sutures, 

565 
raspatories  for.  564 
Urea  in  urine,  263 
Ureteral        catheterization, 
technic       in       examining 
small    amounts    of    urine 
as  obtained  Ijy.  266 
Urethral  fever,  44 
Urinary      tract,      infection 
with  colon  bacillus,  urine 
in,  272 
Urine,  albumin  in.  260 
analvsis.  259 
blood  in.  267 
chlorids  in.  263 
cryoscopy  of.  264 
electric    conducti\itv    of, 

265 
glucose  in,  262 
in  acute  catarrh  of  renal 

peh'is.  269 
in  acute  cystitis.  269 
in  chronic  cystitis.  269 
in  colon  bacillus  infection 

of  urinary  tract.  272 
in  cysts  of  kidney.  270 
in  floating  kidney.  270 
in  hydronephrosis.  270 
in  malisnant    tumors    of 

kidney,  270 
in  nephralgia    and    allied 
conditions,  272 


722 


INDEX 


Urine  in  polycystic  degener- 
ation of  kidney,  270 

in  post-anesthetic  neph- 
ritis, 267 

in  pyelitis  with  hyperemia 
of  renal  parenchyma, 
269 

in  pyelonephritis,  270 

in  pyonephrosis,  270 

in     renal    actinomycosis, 
270 
calculus,  271 
tuberculosis,  271 

in  subcutaneous  trauma- 
tism of  kidney,  272 

in  suppurative  nephritis, 
272 

in  syphilitic  renal  hyper- 
plasia, simulating  ma- 
lignant growth,  270 

microscopic  examination, 
263 

pus  in,  267 

quantity,  260 

retention  of,  after  opera- 
tions, 284 

sugar  in,  262 

suppression  of,  after  oper- 
ations, 284 

technic  in  examining 
small  amounts,  as  ob- 
tained by  ureteral  cath- 
eterization, 266 

urea  in,  263 
Urotoxic  coefficient,  265 
Uterine    repositor,    Elliot's, 

385 
Utility,  operations  of,  280 


Vagina,  sarcoma  of,  224 
Valvular  thrombi,  102 
Varices  of  scalp,  434 
Varicose  aneurism,  96 
ulcers,  69 
veins,  100 

rupture  of,  101 
Variolous  laryngitis,  599 
Varix,  100 

aneurismal,  96 
Vein,  jugular,  external,  in- 
juries of,  627 
Veins,  aspiration  of  air  into, 
98 
diseases  of,  98 
injuries  of,  98 
ligation  in  continuity  of, 
351 
lateral,  344 
multiple,  351 
lumen  of,  obliteration  of, 
.     103 

operations  on,  350 
suture  of,  344 


Veins,  varicose,  100 
rupture  of,  101 
Velpeau's  bandage,  415 
Velum  of  soft  palate,     558 
Venereal   sore,   non-syphili- 
tic, 82 
Venesection,  351 

in   wounds   of  heart   and 
pericardium,  685 
Venous  and  arterial  hemor- 
rhage, differential  diag- 
nosis, 99 
angioma,  treatment,  334 
cysts  of  scalp,  434 
hemorrhage,  98 

arrest,  343 
nevi  of  tongue,  556 
stasis,  103 

and    its    consequences, 

103 
gangrene  after,  104,  105 
Vertebrae,      cervical,     641. 
See  also  Cervical  vertebrae. 
Vertebral  artery,  ligation  of, 
637 
column,    cervical,    bursa 
mucosa  of,  649 
carcinoma  of,  649 
congenital   clefts    of, 

649 
inflammatory     affec- 
tions of,  645 
sarcoma  of,  649 
tumors  of,  649 
Villous  papilloma,  229 

intracystic,  230 
Vocal    cords,    paralysis    of, 
after    laryngeal    diphthe- 
ria, 603 
Volkmann's  block,  424 
bone  curet,  318 
method    of    extension    in 
recumbent  position, 647 
Vomiting     and    nausea    in 
anesthesia,  303 


Ware's  apparatus  for  open 

administration    of    ethyl 

chlorid,  303 
Warty   growths,   sessile,   of 

tongue,  557 
Water,  injection  of,  at  high 

temperature,  in  tumors  of 

skin,  334 
Wens,  231 

removal,  334 
White  corpuscles.    See  Leu- 
kocytes. 

thrombus,  104 
Whitehead's  gag,  559 

operation  for  extirpation 
of  entire  tongue  in  can- 
cer, 552 


Whitehead's    operation    for 
extirpation     of     half     of 
tongue  in  cancer,  551 
Wilde's  polypus  snare,  582 
Windlass,  Spanish,  337 
Wire  curet,  500 

saw,  GigU's,  312,  361,  362 
Wood-wool,  63 
Wound  diphtheria,  180 
Wounds,  1 

antiseptic  dressing,  56 
aseptic,  2 

classification  and  mechan- 
ism, 1 
contused,  1 
diseases  of,  acute,  177 
drainage  of,  56 
dressing  of,  55 
foul-smelling     treatment, 

58 
gaping  of,  66 

of  edges,  321 
granulating,  3 
gunshot,  165.       See    also 

Gunshot  injuries. 
healing  by  primary  inten- 
tion, 2 
by  secondary  intention, 

3 
by  third  intention,  6 
histology  of,  4 
origin     of     connective- 
tissue  cells  during,  6 
with  suppuration,  3 
without  suppuration,  2 
hemorrhage  of,  2 
incised,  1 
lacerated,  1 

mechanism  and  classifica- 
tion, 1 
penetrating,  1 
perforating,  1 
poisoned,  2 
punctured,  1 
redressing,  indications  for, 

57 
separation  of,  2 
septic,  2 
symptoms,  2 
Wringer     for     hot     towels, 

gauze,  etc.,  52 
Wrist  and  hand,  figure-of-8 
bandage  of,  418 
palmar        applica- 
tion, 418 
Wryneck,     624,     650.     See 
also  Torticollis. 


ZiEHL  -  Neelsen   stain   for 

tubercle  bacilli,  25 
Zinc  chlorid,  60 

oxid  ointment,  63 


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A  treatise  on  suroery 

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